1. Vessels and nerves of thorax. Anterior branches of thoracic spinal nerves

        1. Vessels and nerves of thorax. Anterior branches of thoracic spinal nerves

        2. Abdominal aorta (paired and unpaired branches)

       3. Arteries and veins of pelvis

 

Lesson # 27

Theme 1.  Vessels and nerves of thorax. Anterior branches of thoracic spinal nerves

 

AORTA is the largest arterial vessel of systemic circulation. It subdivides on ascending part of aorta, aortic arch and descending part of aorta, which has thoracic and abdominal portions of aorta.

Ascending part of aorta leave the left ventricle behind left margin of sternum on level III intercostal space. In initial department it has expansion is aorta bulb, in which three aortic sinuses are contained. Ascending part of aorta lies behind and a little to the right  from pulmonary trunk, rises up and to level of second right costal cartilage passes into arc.

The Arch of the Aorta turns posteriorly to the left from second costal cartilage to left side of fourth thoracic vertebral body, where passes into descending aorta. Between concave aortic arch surface and pulmonary trunk on beginning of left pulmonary artery is situated obliterated arterial Botali duct. From convex aortic arch surface starts to from the right to the left: brachiocephalic trunk, left common carotid and left subclavian artery.

Descending aorta has thoracic part of aorta, which passes in posterior mediastinum and lies to the left from bodies of thoracic vertebrae and abdominal part of aorta, which starts on level of ХІІ thoracic vertebra, passes through aortic hiatus of diaphragm, and extends to level of ІV lumbar vertebra. Abdominal part of aorta is disposed front of anterior surface of lumbar vertebrae to the left from midiane line. Here abdominal aorta gives off the pair parietal branches, pair and odd visceral branches and finishes in bifurcation, dividing into two common iliac arteries.

Branches of thoracic part of aorta

Parietal branches and visceral branches there distinguish in thoracic part of aorta.

Follow arteries belong to parietal branches of thoracic part of aorta:

-         superior phrenic arteries are pair, pass to lumbar part of diaphragm;

-         posterior intercostal arteries are 10 pairs in number, which pass in ІІІ-XІ intercostal spaces and supply intercostal muscles, ribs, skin, breasts. Lower posterior intercostal arteries supply also muscles of anterior abdominal wall. X posterior intercostal artery is situated under posterior margin of XІІ rib and has a name of subcostal artery. From each posterior intercostal artery move away the sprigs to muscles and posterior skin, to membranes of spinal cord and lateral and medial cutaneі branches to breasts skin and abdominal, sprigs to mammary gland.

Follow arteries belong to visceral branches of thoracic part of aorta:

-         bronchial branches - to trachea, bronchі and lung;

-         esophageal branches to esophagus;

-         pericardial branches to posterior part of pericardium;

-         mediastinal branches supply connective tissue and lymphatic nodes in posterior mediastinum.

 

The thoracic aorta, viewed from the left side.

 

 

Relations. It is in relation, anteriorly, from above downward, with the root of the left lung, the pericardium, the esophagus, and the diaphragm; posteriorly, with the vertebral column and the hemiazygos veins; on the right side, with the azygos vein and thoracic duct; on the left side, with the left pleura and lung. The esophagus, with its accompanying plexus of nerves, lies on the right side of the aorta above; but at the lower part of the thorax it is placed in front of the aorta, and, close to the diaphragm, is situated on its left side.

 

Peculiarities. The aorta is occasionally found to be obliterated at the junction of the arch with the thoracic aorta, just below the ductus arteriosus. Whether this is the result of disease, or of congenital malformation, is immaterial to our present purpose; it affords an interesting opportunity of observing the resources of the collateral circulation. The course of the anastomosing vessels, by which the blood is brought from the upper to the lower part of the artery, will be found well described in an account of two cases in the Pathological Transactions, vols. viii and x. In the former, Sydney Jones thus sums up the detailed description of the anastomosing vessels: The principal communications by which the circulation was carried on were: (1) The internal mammary, anastomosing with the intercostal arteries, with the inferior phrenic of the abdominal aorta by means of the musculophrenic and pericardiacophrenic, and largely with the inferior epigastric. (2) The costocervical trunk, anastomosing anteriorly by means of a large branch with the first aortic intercostal, and posteriorly with the posterior branch of the same artery. (3) The inferior thyroid, by means of a branch about the size of an ordinary radial, forming a communication with the first aortic intercostal. (4) The transverse cervical, by means of very large communications with the posterior branches of the intercostals. (5) The branches (of the subclavian and axillary) going to the side of the chest were large, and anastomosed freely with the lateral branches of the intercostals. In the second case Wood describes the anastomoses in a somewhat similar manner, adding the remark that “the blood which was brought into the aorta through the anastomosis of the intercostal arteries appeared to be expended principally in supplying the abdomen and pelvis; while the supply to the lower extremities had passed through the internal mammary and epigastrics.”

  In a few cases an apparently double descending thoracic aorta has been found, the two vessels lying side by side, and eventually fusing to form a single tube in the lower part of the thorax or in the abdomen. One of them is the aorta, the other represents a dissecting aortic aneurism which has become canalized; opening above and below into the true aorta, and at first sight presenting the appearances of a proper bloodvessel.

 

Branches of the Thoracic Aorta.

 

  The pericardial branches (rami pericardiaci) consist of a few small vessels which are distributed to the posterior surface of the pericardium.

  The bronchial arteries (aa. bronchiales) vary in number, size, and origin. There is as a rule only one right bronchial artery, which arises from the first aortic intercostal, or from the upper left bronchial artery. The left bronchial arteries are usually two in number, and arise from the thoracic aorta. The upper left bronchial arises opposite the fifth thoracic vertebra, the lower just below the level of the left bronchus. Each vessel runs on the back part of its bronchus, dividing and subdividing along the bronchial tubes, supplying them, the areolar tissue of the lungs, the bronchial lymph glands, and the esophagus.

  The esophageal arteries (aa. æsophageæ) four or five in number, arise from the front of the aorta, and pass obliquely downward to the esophagus, forming a chain of anastomoses along that tube, anastomosing with the esophageal branches of the inferior thyroid arteries above, and with ascending branches from the left inferior phrenic and left gastric arteries below.

  The mediastinal branches (rami mediastinales) are numerous small vessels which supply the lymph glands and loose areolar tissue in the posterior mediastinum.

 

Intercostal Arteries (aa. intercostales).—There are usually nine pairs of aortic intercostal arteries. They arise from the back of the aorta, and a redistributed to the lower nine intercostal spaces, the first two spaces being supplied by the highest intercostal artery, a branch of the costocervical trunk of the subclavian. The right aortic intercostals are longer than the left, on account of the position of the aorta on the left side of the vertebral column; they pass across the bodies of the vertebræ behind the esophagus, thoracic duct, and vena azygos, and are covered by the right lung and pleura. The left aortic intercostals run backward on the sides of the vertebræ and are covered by the left lung and pleura; the upper two vessels are crossed by the highest left intercostal vein, the lower vessels by the hemiazygos veins. The further course of the intercostal arteries is practically the same on both sides. Opposite the heads of the ribs the sympathetic trunk passes downward in front of them, and the splanchnic nerves also descend in front by the lower arteries. Each artery then divides into an anterior and a posterior ramus.

  The Anterior Ramus crosses the corresponding intercostal space obliquely toward the angle of the upper rib, and thence is continued forward in the costal groove. It is placed at first between the pleura and the posterior intercostal membrane, then it pierces this membrane, and lies between it and the Intercostalis externus as far as the angle of the rib; from this onward it runs between the Intercostales externus and internus, and anastomoses in front with the intercostal branch of the internal mammary or musculophrenic. Each artery is accompanied by a vein and a nerve, the former being above and the latter below the artery, except in the upper spaces, where the nerve is at first above the artery. The first aortic intercostal artery anastomoses with the intercostal branch of the costocervical trunk, and may form the chief supply of the second intercostal space. The lower two intercostal arteries are continued anteriorly from the intercostal spaces into the abdominal wall, and anastomose with the subcostal, superior epigastric, and lumbar arteries.

 

Branches.—The anterior rami give off the following branches:

 

  The collateral intercostal branch comes off from the intercostal artery near the angle of the rib, and descends to the upper border of the rib below, along which it courses to anastomose with the intercostal branch of the internal mammary.

  Muscular branches are given to the Intercostales and Pectorales and to the Serratus anterior; they anastomose with the highest and lateral thoracic branches of the axillary artery.

  The lateral cutaneous branches accompany the lateral cutaneous branches of the thoracic nerves.

  Mammary branches are given off by the vessels in the third, fourth, and fifth spaces. They supply the mamma, and increase considerably in size during the period of lactation.

  The Posterior Ramus runs backward through a space which is bounded above and below by the necks of the ribs, medially by the body of a vertebra, and laterally by an anterior costotransverse ligament. It gives off a spinal branch which enters the vertebral canal through the intervertebral foramen and is distributed to the medulla spinalis and its membranes and the vertebræ. It then courses over the transverse process with the posterior division of the thoracic nerve, supplies branches to the muscles of the back and cutaneous branches which accompany the corresponding cutaneous branches of the posterior division of the nerve.

  The subcostal arteries, so named because they lie below the last ribs, constitute the lowest pair of branches derived from the thoracic aorta, and are in series with the intercostal arteries. Each passes along the lower border of the twelfth rib behind the kidney and in front of the Quadratus lumborum muscle, and is accompanied by the twelfth thoracic nerve. It then pierces the posterior aponeurosis of the Transversus abdominis, and, passing forward between this muscle and the Obliquus internus, anastomoses with the superior epigastric, lower intercostal, and lumbar arteries. Each subcostal artery gives off a posterior branch which has a similar distribution to the posterior ramus of an intercostal artery.

  The superior phrenic branches are small and arise from the lower part of the thoracic aorta; they are distributed to the posterior part of the upper surface of the diaphragm, and anastomose with the musculophrenic and pericardiacophrenic arteries.

  A small aberrant artery is sometimes found arising from the right side of the thoracic aorta near the origin of the right bronchial. It passes upward and to the right behind the trachea and the esophagus, and may anastomose with the highest right intercostal artery. It represents the remains of the right dorsal aorta, and in a small proportion of cases is enlarged to form the first part of the right subclavian artery.

 

Superior vena cava is generated by reason of confluence of right and left brachiocephalic veins behind joint of cartilage of first right rib with sternum. Superior vena cava on level of third right cartilage empties into right atrium. Azygos vein empties into superior vena cava from right side.

Brachiocephalic veins form by the confluence of subclavian vein, internal jugular and sometimes External jugular vein. This place is called as venous angle, where thoracic lymphatic duct empties (left side), and right lymphatic duct (right side). Inferior thyroid veins from thyroid plexus, inferior laryngeal vein and thymic vein, pericardial veins from pericardium, bronchic veins and esophageal veins from esophagus fall into brachiocephalic veins.

Azygos vein continues into thoracic cavity from right ascending lumbar vein. Azygos vein receives posterior intercostal veins, esophageal veins, bronchic veins, pericardial veins and mediastinal veins, also hemizygos vein.

  The Veins of the Thorax The brachiocephalic veins (vv. anonymæ; brachiocephalic veins) are two large trunks, placed one on either side of the root of the neck, and formed by the union of the internal jugular and subclavian veins of the corresponding side; they are devoid of valves.

  The Right Brachiocephalic Vein (v. anonyma dextra) is a short vessel, about 2.5 cm. in length, which begins behind the sternal end of the clavicle, and, passing almost vertically downward, joins with the left brachiocephalic vein just below the cartilage of the first rib, close to the right border of the sternum, to form the superior vena cava. It lies in front and to the right of the brachiocephalic artery; on its right side are the phrenic nerve and the pleura, which are interposed between it and the apex of the lung. This vein, at its commencement, receives the right vertebral vein; and, lower down, the right internal mammary and right inferior thyroid veins, and sometimes the vein from the first intercostal space.

Transverse section of a thoracic vertebra, showing the vertebral venous plexuses.

Thoracic ganglia of sympathetic trunk (10-12), which are contained near caput of ribs laterally from vertebral bodies. Thoracic ganglia receive the communicating white branches containing preganglionic fibers. Thoracic ganglia give off the following branches:

-         gray communicating branches, which approach to intercostal nerves;

-         thoracic cardiac nerves being a party to forming of cardiac plexus;

-         thoracic pulmonary branches passing to bronchi and lungs, forming pulmonary plexus;

-         thoracic aortic rami, which form thoracic aortic plexus;

-         major splanchnic nerve, formed by branches from VI-IX thoracic ganglia and consist overwhelmingly of preganglionic fibers. This nerve passes through the lumbar part of diaphragm into abdominal cavity and terminates in ganglia of abdominal plexus;

-         minor splanchnic nerve starts from X-XI thoracic sympathetic ganglia and also has preganglionic fibers. It passes down into abdominal cavity (through the lumbar part of diaphragm) and enters into ganglia of abdominal plexus.

The thoracic portion of the sympathetic trunk.

 consists of a series of ganglia, which usually correspond in number to that of the vertebræ; but, on account of the occasional coalescence of two ganglia, their number is uncertain. The thoracic ganglia rest against the heads of the ribs, and are covered by the costal pleura; the last two, however, are more anterior than the rest, and are placed on the sides of the bodies of the eleventh and twelfth thoracic vertebræ. The ganglia are small in size, and of a grayish color. The first, larger than the others, is of an elongated form, and frequently blended with the inferior cervical ganglion. They are connected together by the intervening portions of the trunk.

  Two rami communicantes, a white and a gray, connect each ganglion with its corresponding spinal nerve.

  The branches from the upper five ganglia are very small; they supply filaments to the thoracic aorta and its branches. Twigs from the second, third, and fourth ganglia enter the posterior pulmonary plexus.

  The branches from the lower seven ganglia are large, and white in color; they distribute filaments to the aorta, and unite to form the greater, the lesser, and the lowest splanchnic nerves.

  

The greater splanchnic nerve (n. splanchnicus major; great splanchnic nerve) is white in color, firm in texture, and of a considerable size; it is formed by branches from the fifth to the ninth or tenth thoracic ganglia, but the fibers in the higher roots may be traced upward in the sympathetic trunk as far as the first or second thoracic ganglion. It descends obliquely on the bodies of the vertebræ, perforates the crus of the diaphragm, and ends in the celiac ganglion. A ganglion (ganglion splanchnicum) exists on this nerve opposite the eleventh or twelfth thoracic vertebra.

  

The lesser splanchnic nerve (n. splanchnicus minor) is formed by filaments from the ninth and tenth, and sometimes the eleventh thoracic ganglia, and from the cord between them. It pierces the diaphragm with the preceding nerve, and joins the aorticorenal ganglion.

  

The lowest splanchnic nerve (n. splanchnicus imus; least splanchnic nerve) arises from the last thoracic ganglion, and, piercing the diaphragm, ends in the renal plexus.

  A striking analogy exists between the splanchnic and the cardiac nerves. The cardiac nerves are three in number; they arise from all three cervical ganglia, and are distributed to a large and important organ in the thoracic cavity. The splanchnic nerves, also three in number, are connected probably with all the thoracic ganglia, and are distributed to important organs in the abdominal cavity.

Thoracic portion of the sympathetic trunk.

Parasympathetic part of X vagus nerve commences in dorsal nucleus of vagus nerve and contains a numerous of intramural ganglia. These ganglia enter to composition of cardiac, esophageal, pulmonary, gastric, intestinal, and others splanchnic plexus. Postganglionic neurons supply smooth muscles, glands and vessels of internal organs in neck, thoracic and abdominal regions.

*                   Thoracic part of vagus nerve gives off:

Thoracic cardiac branches which pass to cardiac plexus;

Bronchial branches with sympathetic nerves form pulmonary plexus. Last enters in lungs with bronchi.

Esophageal branches form esophageal plexus round this organ.

The Inferior Cardiac Branches (rami cardiaci inferiores; thoracic cardiac branches), on the right side, arise from the trunk of the vagus as it lies by the side of the trachea, and from its recurrent nerve; on the left side from the recurrent nerve only; passing inward, they end in the deep part of the cardiac plexus.

  The Anterior Bronchial Branches (rami bronchiales anteriores; anterior or ventral pulmonary branches), two or three in number, and of small size, are distributed on the anterior surface of the root of the lung. They join with filaments from the sympathetic, and form the anterior pulmonary plexus.

  The Posterior Bronchial Branches (rami bronchiales posteriores; posterior or dorsal pulmonary branches), more numerous and larger than the anterior, are distributed on the posterior surface of the root of the lung; they are joined by filaments from the third and fourth (sometimes also from the first and second) thoracic ganglia of the sympathetic trunk, and form the posterior pulmonary plexus. Branches from this plexus accompany the ramifications of the bronchi through the substance of the lung.

  The Esophageal Branches (rami æsophagei) are given off both above and below the bronchial branches; the lower are numerous and larger than the upper. They form, together with the branches from the opposite nerve, the esophageal plexus. From this plexus filaments are distributed to the back of the pericardium.

Intercostal nerves

12 pairs of the ventral rami of the thoracic spinal nerves run between the ribs as intercostal nerves (the 12^th nerve called subcostal nerve). They pass in sulcus costae between the external and internal intercostal muscles and supply them, also the transverse thoracic muscle. Six upper intercostal nerves give off anterior and lateral cutaneous branches for skin in chest region, also medial (Th_II-IV) and lateral (Th_IV-VI) mammary branches for innervating the breast. Six lower intercostal nerves pass into hte depth of the abdominal muscles, into the sheath of the rectus abdominis muscle and supply muscles (*) and skin in anterior and lateral abdominal region (* - rectus abdominis, external, internal oblique and tranverse abdominis,  pyramidalis muscles).

 

The anterior divisions of the thoracic nerves (rami anteriores; ventral divisions) are twelve in number on either side. Eleven of them are situated between the ribs, and are therefore termed intercostal; the twelfth lies below the last rib. Each nerve is connected with the adjoining ganglion of the sympathetic trunk by a gray and a white ramus communicans. The intercostal nerves are distributed chiefly to the parietes of the thorax and abdomen, and differ from the anterior divisions of the other spinal nerves, in that each pursues an independent course, i. e., there is no plexus formation. The first two nerves supply fibers to the upper limb in addition to their thoracic branches; the next four are limited in their distribution to the parietes of the thorax; the lower five supply the parietes of the thorax and abdomen. The twelfth thoracic is distributed to the abdominal wall and the skin of the buttock.

 

The First Thoracic Nerve.—The anterior division of the first thoracic nerve divides into two branches: one, the larger, leaves the thorax in front of the neck of the first rib, and enters the brachial plexus; the other and smaller branch, the first intercostal nerve, runs along the first intercostal space, and ends on the front of the chest as the first anterior cutaneous branch of the thorax. Occasionally this anterior cutaneous branch is wanting. The first intercostal nerve as a rule gives off no lateral cutaneous branch; but sometimes it sends a small branch to communicate with the intercostobrachial. From the second thoracic nerve it frequently receives a connecting twig, which ascends over the neck of the second rib.

Diagram of the course and branches of a typica intercostal nerve.

 

 

The Upper Thoracic Nerves (nn. intercostales).—The anterior divisions of the second, third, fourth, fifth, and sixth thoracic nerves, and the small branch from the first thoracic, are confined to the parietes of the thorax, and are named thoracic intercostal nerves. They pass forward  in the intercostal spaces below the intercostal vessels. At the back of the chest they lie between the pleura and the posterior intercostal membranes, but soon pierce the latter and run between the two planes of Intercostal muscles as far as the middle of the rib. They then enter the substance of the Intercostales interni, and, running amidst their fibers as far as the costal cartilages, they gain the inner surfaces of the muscles and lie between them and the pleura. Near the sternum, they cross in front of the internal mammary artery and Transversus thoracis muscle, pierce the Intercostales interni, the anterior intercostal membranes, and Pectoralis major, and supply the integument of the front of the thorax and over the mamma, forming the anterior cutaneous branches of the thorax; the branch from the second nerve unites with the anterior supraclavicular nerves of the cervical plexus.

 

Branches.—Numerous slender muscular filaments supply the Intercostales, the Subcostales, the Levatores costarum, the Serratus posterior superior, and the Transversus thoracis. At the front of the thorax some of these branches cross the costal cartilages from one intercostal space to another.

  Lateral cutaneous branches (rami cutanei laterales) are derived from the intercostal nerves, about midway between the vertebræ and sternum; they pierce the Intercostales externi and Serratus anterior, and divide into anterior and posterior branches. The anterior branches run forward to the side and the forepart of the chest, supplying the skin and the mamma; those of the fifth and sixth nerves supply the upper digitations of the Obliquus externus abdominis. The posterior branches run backward, and supply the skin over the scapula and Latissimus dorsi.

  The lateral cutaneous branch of the second intercostal nerve does not divide, like the others, into an anterior and a posterior branch; it is named the intercostobrachial nerve. It pierces the Intercostalis externus and the Serratus anterior, crosses the axilla to the medial side of the arm, and joins with a filament from the medial brachial cutaneous nerve. It then pierces the fascia, and supplies the skin of the upper half of the medial and posterior part of the arm, communicating with the posterior brachial cutaneous branch of the radial nerve. The size of the intercostobrachial nerve is in inverse proportion to that of the medial brachial cutaneous nerve. A second intercostobrachial nerve is frequently given off from the lateral cutaneous branch of the third intercostal; it supplies filaments to the axilla and medial side of the arm.

 

Cutaneous distribution of thoracic nerves.

 

Intercostal nerves, the superficial muscles having been removed. (Testut).

The Lower Thoracic Nerves.—The anterior divisions of the seventh, eighth, ninth, tenth, and eleventh thoracic nerves are continued anteriorly from the intercostal spaces into the abdominal wall; hence they are named thoracicoabdominal intercostal nerves. They have the same arrangement as the upper ones as far as the anterior ends of the intercostal spaces, where they pass behind the costal cartilages, and between the Obliquus internus and Transversus abdominis, to the sheath of the Rectus abdominis, which they perforate. They supply the Rectus abdominis and end as the anterior cutaneous branches of the abdomen; they supply the skin of the front of the abdomen. The lower intercostal nerves supply the Intercostales and abdominal muscles; the last three send branches to the Serratus posterior inferior. About the middle of their course they give off lateral cutaneous branches. These pierce the Intercostales externi and the Obliquus externus abdominis, in the same line as the lateral cutaneous branches of the upper thoracic nerves, and divide into anterior and posterior branches, which are distributed to the skin of the abdomen and back; the anterior branches supply the digitations of the Obliquus externus abdominis, and extend downward and forward nearly as far as the margin of the Rectus abdominis; the posterior branches pass backward to supply the skin over the Latissimus dorsi.

  The anterior division of the twelfth thoracic nerve is larger than the others; it runs along the lower border of the twelfth rib, often gives a communicating branch to the first lumbar nerve, and passes under the lateral lumbocostal arch. It then runs in front of the Quadratus lumborum, perforates the Transversus, and passes forward between it and the Obliquus internus to be distributed in the same manner as the lower intercostal nerves. It communicates with the iliohypogastric nerve of the lumbar plexus, and gives a branch to the Pyramidalis. The lateral cutaneous branch of the last thoracic nerve is large, and does not divide into an anterior and a posterior branch. It perforates the Obliqui internus and externus, descends over the iliac crest in front of the lateral cutaneous branch of the iliohypogastric, and is distributed to the skin of the front part of the gluteal region, some of its filaments extending as low as the greater trochanter.

 

 

Theme 2. Abdominal aorta. Parietal  and visceral branches

 

А. gastropancreaticа            The abdominal aorta begins at the aortic hiatus of the diaphragm, in front of the lower border of the body of the last thoracic vertebra, and, descending in front of the vertebral column, ends on the body of the fourth lumbar vertebra, commonly a little to the left of the middle line, (533) is a short but large branch, which descends, near the pylorus, between the superior part of the duodenum and the neck of the pancreas, and divides at the lower border of the duodenum into two branches, the right gastroepiploic and the superior pancreaticoduodenal. Previous to its division it gives off two or three small branches to the pyloric end of the stomach and to the pancreas.

  The right gastroepiploic artery (a. gastroepiploica dextra) runs from right to left along the greater curvature of the stomach, between the layers of the greater omentum, anastomosing with the left gastroepiploic branch of the lienal artery. Except at the pylorus where it is in contact with the stomach, it lies about a finger's breadth from the greater curvature. This vessel gives off numerous branches, some of which ascend to supply both surfaces of the stomach, while others descend to supply the greater omentum and anastomose with branches of the middle colic.

  The superior pancreaticoduodenal artery (a. pancreaticoduodenalis superior) descends between the contiguous margins of the duodenum and pancreas. It supplies both these organs, and anastomoses with the inferior pancreaticoduodenal branch of the superior mesenteric artery, and with the pancreatic branches of the lienal artery.

 

The celiac artery and its branches; the stomach has been raised and the peritoneum removed.

  

 

  The cystic artery (a. cystica), usually a branch of the right hepatic, passes downward and forward along the neck of the gall-bladder, and divides into two branches, one of which ramifies on the free surface, the other on the attached surface of the gall-bladder.

  3. The Lienal or Splenic Artery (a. lienalis), the largest branch of the celiac artery, is remarkable for the tortuosity of its course. It passes horizontally to the left side, behind the stomach and the omental bursa of the peritoneum, and along the upper border of the pancreas, accompanied by the lienal vein, which lies below it; it crosses in front of the upper part of the left kidney, and, on arriving near the spleen, divides into branches, some of which enter the hilus of that organ between the two layers of the phrenicolienal ligament to be distributed to the tissues of the spleen; some are given to the pancreas, while others pass to the greater curvature of the stomach between the layers of the gastrolienal ligament. Its branches are:

Pancreatic.

Short Gastric.

Left Gastroepiploic.

 

  The pancreatic branches (rami pancreatici) are numerous small vessels derived from the lienal as it runs behind the upper border of the pancreas, supplying its body and tail. One of these, larger than the rest, is sometimes given off near the tail of the pancreas; it runs from left to right near the posterior surface of the gland, following the course of the pancreatic duct, and is called the arteria pancreatica magna. These vessels anastomose with the pancreatic branches of the pancreaticoduodenal and superior mesenteric arteries.

 

Inferior Pancreaticoduodenal.

Ileocolic.

Intestinal.

Right Colic.

Middle Colic.

 

  The Inferior Pancreaticoduodenal Artery (a. pancreaticoduodenalis inferior) is given off from the superior mesenteric or from its first intestinal branch, opposite the upper border of the inferior part of the duodenum. It courses to the right between the head of the pancreas and duodenum, and then ascends to anastomose with the superior pancreaticoduodenal artery. It distributes branches to the head of the pancreas and to the descending and inferior parts of the duodenum.   The Intestinal Arteries (aa. intestinales; vasa intestini tenuis) arise from the convex side of the superior mesenteric artery. They are usually from twelve to fifteen in number, and are distributed to the jejunum and ileum. They run nearly parallel with one another between the layers of the mesentery, each vessel dividing into two branches, which unite with adjacent branches, forming a series of arches, the convexities of which are directed toward the intestine. From this first set of arches branches arise, which unite with similar branches from above and below and thus a second series of arches is formed; from the lower branches of the artery, a third, a fourth, or even a fifth series of arches may be formed, diminishing in size the nearer they approach the intestine. In the short, upper part of the mesentery only one set of arches exists, but as the depth of the mesentery increases, second, third, fourth, or even fifth groups are developed. From the terminal arches numerous small straight vessels arise which encircle the intestine, upon which they are distributed, ramifying between its coats. From the intestinal arteries small branches are given off to the lymphatic nodes and other structures between the layers of the mesentery.

  The Ileocolic Artery (a. ileocolica) is the lowest branch arising from the concavity of the superior mesenteric artery. It passes downward and to the right behind the peritoneum toward the right iliac fossa, where it divides into a superior and an inferior branch; the inferior anastomoses with the end of the superior mesenteric artery, the superior with the right colic artery.

(a) colic, which pass upward on the ascending colon; (b) anterior and posterior cecal, which are distributed to the front and back of the cecum; (c) anappendicular artery, which descends behind the termination of the ileum and enters the mesenteriole of the vermiform process; it runs near the free margin of this mesenteriole and ends in branches which supply the vermiform process; and (d) ileal, which run upward and to the left on the lower part of the ileum, and anastomose with the termination of the superior mesenteric.

The Right Colic Artery (a. colica dextra) arises from about the middle of the concavity of the superior mesenteric artery, or from a stem common to it and the ileocolic. It passes to the right behind the peritoneum, and in front of the right internal spermatic or ovarian vessels, the right ureter and the Psoas major, toward the middle of the ascending colon; sometimes the vessel lies at a higher level, and crosses the descending part of the duodenum and the lower end of the right kidney. At the colon it divides into a descending branch, which anastomoses with the ileocolic, and an ascending branch, which anastomoses with the middle colic. These branches form arches, from the convexity of which vessels are distributed to the ascending colon.

The Middle Colic Artery (a. colica media) arises from the superior mesenteric just below the pancreas and, passing downward and forward between the layers of the transverse mesocolon, divides into two branches, right and left; the former anastomoses with the right colic; the latter with the left colic, a branch of the inferior mesenteric. The arches thus formed are placed about two fingers’ breadth from the transverse colon, to which they distribute branches.

The inferior mesenteric artery (a. mesenterica inferior)  supplies the left half of the transverse part of the colon, the whole of the descending and iliac parts of the colon, the sigmoid colon, and the greater part of the rectum. It is smaller than the superior mesenteric, and arises from the aorta, about 3 or 4 cm. above its division into the common iliacs and close to the lower border of the inferior part of the duodenum. It passes downward posterior to the peritoneum, lying at first anterior to and then on the left side of the aorta. It crosses the left common iliac artery and is continued into the lesser pelvis under the name of the superior hemorrhoidal artery, which descends between the two layers of the sigmoid mesocolon and ends on the upper part of the rectum.

Branches.—Its branches are:

Left Colic.

Sigmoid.

Superior Hemorrhoidal.

The Left Colic Artery (a. colica sinistra) runs to the left behind the peritoneum and in front of the Psoas major, and after a short, but variable, course divides into an ascending and a descending branch; the stem of the artery or its branches cross the left ureter and left internal spermatic vessels. The ascending branch crosses in front of the left kidney and ends, between the two layers of the transverse mesocolon, by anastomosing with the middle colic artery; the descending branch anastomoses with the highest sigmoid artery. From the arches formed by these anastomoses branches are distributed to the descending colon and the left part of the transverse colon.

The Sigmoid Arteries (aa. sigmoideæ)  two or three in number, run obliquely downward and to the left behind the peritoneum and in front of the Psoas major, ureter, and internal spermatic vessels. Their branches supply the lower part of the descending colon, the iliac colon, and the sigmoid or pelvic colon; anastomosing above with the left colic, and below with the superior hemorrhoidal artery.

The Superior Hemorrhoidal Artery (a. hæmorrhoidalis superior)  the continuation of the inferior mesenteric, descends into the pelvis between the layers of the mesentery of the sigmoid colon, crossing, in its course, the left common iliac vessels. It divides, opposite the third sacral vertebra, into two branches, which descend one on either side of the rectum, and about 10 or 12 cm. from the anus break up into several small branches. These pierce the muscular coat of the bowel and run downward, as straight vessels, placed at regular intervals from each other in the wall of the gut between its muscular and mucous coats, to the level of the Sphincter ani internus; here they form a series of loops around the lower end of the rectum, and communicate with the middle hemorrhoidal branches of the hypogastric, and with the inferior hemorrhoidal branches of the internal pudendal.

The middle suprarenal arteries (aa. suprarenales media; middle capsular arteries; suprarenal arteries) are two small vessels which arise, one from either side of the aorta, opposite the superior mesenteric artery. They pass lateralward and slightly upward, over the crura of the diaphragm, to the suprarenal glands, where they anastomose with suprarenal branches of the inferior phrenic and renal arteries. In the fetus these arteries are of large size.

The renal arteries (aa. renales)  are two large trunks, which arise from the side of the aorta, immediately below the superior mesenteric artery. Each is directed across the crus of the diaphragm, so as to form nearly a right angle with the aorta. The right is longer than the left, on account of the position of the aorta; it passes behind the inferior vena cava, the right renal vein, the head of the pancreas, and the descending part of the duodenum. The left is somewhat higher than the right; it lies behind the left renal vein, the body of the pancreas and the lienal vein, and is crossed by the inferior mesenteric vein. Before reaching the hilus of the kidney, each artery divides into four or five branches; the greater number of these lie between the renal vein and ureter, the vein being in front, the ureter behind, but one or more branches are usually situated behind the ureter. Each vessel gives off some small inferior suprarenal branches to the suprarenal gland, the ureter, and the surrounding cellular tissue and muscles. One or two accessory renal arteries are frequently found, more especially on the left side they usually arise from the aorta, and may come off above or below the main artery, the former being the more common position. Instead of entering the kidney at the hilus, they usually pierce the upper or lower part of the gland.

The internal spermatic arteries (aa. spermaticæ internæ; spermatic arteries)  are distributed to the testes. They are two slender vessels of considerable length, and arise from the front of the aorta a little below the renal arteries. Each passes obliquely downward and lateralward behind the peritoneum, resting on the Psoas major, the right spermatic lying in front of the inferior vena cava and behind the middle colic and ileocolic arteries and the terminal part of the ileum, the left behind the left colic and sigmoid arteries and the iliac colon. Each crosses obliquely over the ureter and the lower part of the external iliac artery to reach the abdominal inguinal ring, through which it passes, and accompanies the other constituents of the spermatic cord along the inguinal canal to the scrotum, where it becomes tortuous, and divides into several branches. Two or three of these accompany the ductus deferens, and supply the epididymis, anastomosing with the artery of the ductus deferens; others pierce the back part of the tunica albuginea, and supply the substance of the testis. The internal spermatic artery supplies one or two small branches to the ureter, and in the inguinal canal gives one or two twigs to the Cremaster.

The ovarian arteries (aa. ovaricæ) are the corresponding arteries in the female to the internal spermatic in the male. They supply the ovaries, are shorter than the internal spermatics, and do not pass out of the abdominal cavity. The origin and course of the first part of each artery are the same as those of the internal spermatic, but on arriving at the upper opening of the lesser pelvis the ovarian artery passes inward, between the two layers of the ovariopelvic ligament and of the broad ligament of the uterus, to be distributed to the ovary. Small branches are given to the ureter and the uterine tube, and one passes on to the side of the uterus, and unites with the uterine artery. Other offsets are continued on the round ligament of the uterus, through the inguinal canal, to the integument of the labium majus and groin.

At an early period of fetal life, when the testes or ovaries lie by the side of the vertebral column, below the kidneys, the internal spermatic or ovarian arteries are short; but with the descent of these organs into the scrotum or lesser pelvis, the arteries are gradually lengthened.

The inferior phrenic arteries (aa. phrenicæ inferiores)  are two small vessels, which supply the diaphragm but present much variety in their origin. They may arise separately from the front of the aorta, immediately above the celiac artery, or by a common trunk, which may spring either from the aorta or from the celiac artery. Sometimes one is derived from the aorta, and the other from one of the renal arteries; they rarely arise as separate vessels from the aorta. They diverge from one another across the crura of the diaphragm, and then run obliquely upward and lateralward upon its under surface. The left phrenic passes behind the esophagus, and runs forward on the left side of the esophageal hiatus. The right phrenic passes behind the inferior vena cava, and along the right side of the foramen which transmits that vein. Near the back part of the central tendon each vessel divides into a medial and a lateral branch. The medial branch curves forward, and anastomoses with its fellow of the opposite side, and with the musculophrenic and pericardiacophrenic arteries. The lateral branch passes toward the side of the thorax, and anastomoses with the lower intercostal arteries, and with the musculophrenic. The lateral branch of the right phrenic gives off a few vessels to the inferior vena cava; and the left one, some branches to the esophagus. Each vessel gives off superior suprarenal branches to the suprarenal gland of its own side. The spleen and the liver also receive a few twigs from the left and right vessels respectively.

The lumbar arteries (aa. lumbales) are in series with the intercostals. They are usually four in number on either side, and arise from the back of the aorta, opposite the bodies of the upper four lumbar vertebræ. A fifth pair, small in size, is occasionally present: they arise from the middle sacral artery. They run lateralward and backward on the bodies of the lumbar vertebræ, behind the sympathetic trunk, to the intervals between the adjacent transverse processes, and are then continued into the abdominal wall. The arteries of the right side pass behind the inferior vena cava, and the upper two on each side run behind the corresponding crus of the diaphragm. The arteries of both sides pass beneath the tendinous arches which give origin to the Psoas major, and are then continued behind this muscle and the lumbar plexus. They now cross the Quadratus lumborum, the upper three arteries running behind, the last usually in front of the muscle. At the lateral border of the Quadratus lumborum they pierce the posterior aponeurosis of the Transversus abdominis and are carried forward between this muscle and the Obliquus internus. They anastomose with the lower intercostal, the subcostal, the iliolumbar, the deep iliac circumflex, and the inferior epigastric arteries.

Arteries of pelvis

On level ІV of lumbar vertebra abdominal aorta divides into two common iliac arteries - aorta bifurcation.

 Common iliac artery passes downward into lesser pelvis and on level of sacrо-iliac joint divides into external iliac artery and internal iliac artery:

 

Internal Iliac Artery supplies the walls and viscera of the pelvis, the buttock, the generative organs, and the medial side of the thigh. It is a short, thick vessel, smaller than the external iliac, and about 4 cm. in length. It arises at the bifurcation of the common iliac, opposite the lumbosacral articulation, and, passing downward to the upper margin of the greater sciatic foramen, divides into two large trunks, an anterior and a posterior.

 

Relations.—It is in relation in front with the ureter; behind, with the internal iliac vein, the lumbosacral trunk, and the Piriformis muscle; laterally, near its origin, with the external iliac vein, which lies between it and the Psoas major muscle; lower down, with the obturator nerve.

  In the fetus, the hypogastric artery is twice as large as the external iliac, and is the direct continuation of the common iliac. It ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta.

  At birth, when the placental circulation ceases, the pelvic portion only of the artery remains patent and constitutes the hypogastric and the first part of the superior vesical artery of the adult; the remainder of the vessel is converted into a solid fibrous cord, the lateral umbilical ligament (obliterated hypogastric artery) which extends from the pelvis to the umbilicus.

Peculiarities as Regards Length.—In two-thirds of a large number of cases, the length of the hypogastric varied between 2.25 and 3.4 cm.; in the remaining third it was more frequently longer than shorter, the maximum length being about 7 cm. the minimum about 1 cm.

  The lengths of the common iliac and hypogastric arteries bear an inverse proportion to each other, the hypogastric artery being long when the common iliac is short, and vice versa.

 

As Regards its Place of Division.—The place of division of the hypogastric varies between the upper margin of the sacrum and the upper border of the greater sciatic foramen.

  The right and left hypogastric arteries in a series of cases often differed in length, but neither seemed constantly to exceed the other.

 

Collateral Circulation.—The circulation after ligature of the hypogastric artery is carried on by the anastomoses of the uterine and ovarian arteries; of the vesical arteries of the two sides; of the hemorrhoidal branches of the hypogastric with those from the inferior mesenteric; of the obturator artery, by means of its pubic branch, with the vessel of the opposite side, and with the inferior epigastric and medial femoral circumflex; of the circumflex and perforating branches of the profunda femoris with the inferior gluteal; of the superior gluteal with the posterior branches of the lateral sacral arteries; of the iliolumbar with the last lumbar; of the lateral sacral with the middle sacral; and of the iliac circumflex with the iliolumbar and superior gluteal. 

 

 

 

Branches.—The branches of the hypogastric artery are:

From the Anterior Trunk.

From the Posterior Trunk.

Superior Vesical.

Iliolumbar.

Middle Vesical.

Lateral Sacral.

Inferior Vesical.

Superior Gluteal.

Middle Hemorrhoidal.

Obturator.

Internal Pudendal.

Inferior Gluteal.

Uterine

In the Female.

Vaginal

  The superior vesical artery (a. vesicalis superior) supplies numerous branches to the upper part of the bladder. From one of these a slender vessel, the artery to the ductus deferens, takes origin and accompanies the duct in its course to the testis, where it anastomoses with the internal testicular artery. Other branches supply the ureter. The first part of the superior vesical artery represents the terminal section of the pervious portion of the fetal hypogastric artery.

  The middle vesical artery (a. vesicalis medialis), usually a branch of the superior, is distributed to the fundus of the bladder and the vesiculæ seminales.

  The inferior vesical artery (a. vesicalis inferior) frequently arises in common with the middle hemorrhoidal, and is distributed to the fundus of the bladder, the prostate, and the vesiculæ seminales. The branches to the prostate communicate with the corresponding vessels of the opposite side.

  The middle hemorrhoidal artery (a. hæmorrhoidalis media) usually arises with the preceding vessel. It is distributed to the rectum, anastomosing with the inferior vesical and with the superior and inferior hemorrhoidal arteries. It gives offsets to the vesiculæ seminales and prostate.

  The uterine artery (a. uterina)  springs from the anterior division of the hypogastric and runs medialward on the Levator ani and toward the cervix uteri; about 2 cm. from the cervix it crosses above and in front of the ureter, to which it supplies a small branch. Reaching the side of the uterus it ascends in a tortuous manner between the two layers of the broad ligament to the junction of the uterine tube and uterus. It then runs lateralward toward the hilus of the ovary, and ends by joining with the ovarian artery. It supplies branches to the cervix uteri and others which descend on the vagina; the latter anastomose with branches of the vaginal arteries and form with them two median longitudinal vessels—the azygos arteries of the vagina—one of which runs down in front of and the other behind the vagina. It supplies numerous branches to the body of the uterus, and from its terminal portion twigs are distributed to the uterine tube and the round ligament of the uterus.

  The vaginal artery (a. vaginalis) usually corresponds to the inferior vesical in the male; it descends upon the vagina, supplying its mucous membrane, and sends branches to the bulb of the vestibule, the fundus of the bladder, and the contiguous part of the rectum. It assists in forming the azygos arteries of the vagina, and is frequently

represented by two or three branches.

from the pelvic cavity through the obturator canal, it divides into an anterior and a posterior branch. In the pelvic cavity this vessel is in relation, laterally, with the obturator fascia; medially, with the ureter, ductus deferens, and peritoneum; while a little below it is the obturator nerve.

 

Branches.—Inside the pelvis the obturator artery gives off iliac branches to the iliac fossa, which supply the bone and the Iliacus, and anastomose with the ilio-lumbar artery; a vesical branch, which runs backward to supply the bladder; and a public branch, which is given off from the vessel just before it leaves the pelvic cavity. The pubic branch ascends upon the back of the pubis, communicating with the corresponding vessel of the opposite side, and with the inferior epigastric artery.

  Outside the pelvis, the obturator artery divides at the upper margin of the obturator foramen, into an anterior and a posterior branch which encircle the foramen under cover of the Obturator externus.

  The anterior branch runs forward on the outer surface of the obturator membrane and then curves downward along the anterior margin of the foramen. It distributes branches to the Obturator externus, Pectineus, Adductores, and Gracilis, and anastomoses with the posterior branch and with the medial femoral circumflex artery.

  The posterior branch follows the posterior margin of the foramen and turns forward on the inferior ramus of the ischium, where it anastomoses with the anterior branch. It gives twigs to the muscles attached to the ischial tuberosity and anastomoses with the inferior gluteal. It also supplies an articular branch which enters the hip-joint through the acetabular notch, ramifies in the fat at the bottom of the acetabulum and sends a twig along the ligamentum teres to the head of the femur.

 

Peculiarities.—The obturator artery sometimes arises from the main stem or from the posterior trunk of the hypogastric, or it may spring from the superior gluteal artery; occasionally it arises from the external iliac. In about two out of every seven cases it springs from the inferior epigastric and descends almost vertically to the upper part of the obturator foramen. The artery in this course usually lies in contact with the external iliac vein, and on the lateral side of the femoral ring; in such cases it would not be endangered in the operation for strangulated femoral hernia. Occasionally, however, it curves along the free margin of the lacunar ligament, and if in such circumstances a femoral hernia occurred, the vessel would almost completely encircle the neck of the hernial sac, and would be in great danger of being wounded if an operation were performed for strangulation.

 

 

    The internal pudendal artery (a. pudenda interna; internal pudic artery) is the smaller of the two terminal branches of the anterior trunk of the hypogastric, and supplies the external organs of generation. Though the course of the artery is the same in the two sexes, the vessel is smaller in the female than in the male, and the distribution of its branches somewhat different. The description of its arrangement in the male will first be given, and subsequently the differences which it presents in the female will be mentioned.

  The internal pudendal artery in the male passes downward and outward to the lower border of the greater sciatic foramen, and emerges from the pelvis between the Piriformis and Coccygeus; it then crosses the ischial spine, and enters the perineum through the lesser sciatic foramen. The artery now crosses the Obturator internus, along the lateral wall of the ischiorectal fossa, being situated about 4 cm. above the lower margin of the ischial tuberosity. It gradually approaches the margin of the inferior ramus of the ischium and passes forward between the two layers of the fascia of the urogenital diaphragm; it then runs forward along the medial margin of the inferior ramus of the pubis, and about 1.25 cm. behind the pubic arcuate ligament it pierces the inferior fascia of the urogenital diaphragm and divides into the dorsal and deep arteries of the penis.

 

Relations.—Within the pelvis, it lies in front of the Piriformis muscle, the sacral plexus of nerves, and the inferior gluteal artery. As it crosses the ischial spine, it is covered by the Glutæus maximus and overlapped by the sacrotuberous ligament. Here the pudendal nerve lies to the medial side and the nerve to the Obturator internus to the lateral side of the vessel. In the perineum it lies on the lateral wall of the ischiorectal fossa, in a canal (Alcock’s canal) formed by the splitting of the obturator fascia. It is accompanied by a pair of venæ comitantes and the pudendal nerve.

 

Peculiarities.—The internal pudendal artery is sometimes smaller than usual, or fails to give off one or two of its usual branches; in such cases the deficiency is supplied by branches derived from an additional vessel, the accessory pudendal, which generally arises from the internal pudendal artery before its exit from the greater sciatic foramen. It passes forward along the lower part of the bladder and across the side of the prostate to the root of the penis, where it perforates the urogenital diaphragm, and gives off the branches usually derived from the internal pudendal artery. The deficiency most frequently met with is that in which the internal pudendal ends as the artery of the urethral bulb, the dorsal and deep arteries of the penis being derived from the accessory pudendal. The internal pudendal artery may also end as the perineal, the artery of the urethral bulb being derived, with the other two branches, from the accessory vessel. Occasionally the accessory pudendal artery is derived from one of the other branches of the hypogastric artery, most frequently the inferior vesical or the obturator.

 

Branches.—The branches of the internal pudendal artery are:

Muscular.

Artery of the Urethral Bulb.

Inferior Hemorrhoidal.

Urethral.

Perineal.

Deep Artery of the Penis.

Dorsal Artery of the Penis.

 

 

The deeper branches of the internal pudendal artery.

 

  The Artery of the Urethral Bulb (a. bulbi urethræ) is a short vessel of large caliber which arises from the internal pudendal between the two layers of fascia of the urogenital diaphragm; it passes medialward, pierces the inferior fascia of the urogenital diaphragm, and gives off branches which ramify in the bulb of the urethra and in the posterior part of the corpus cavernosum urethræ. It gives off a small branch to the bulbo-urethral gland.

  The Urethral Artery (a. urethralis) arises a short distance in front of the artery of the urethral bulb. It runs forward and medialward, pierces the inferior fascia of the urogenital diaphragm and enters the corpus cavernosum urethræ, in which it is continued forward to the glans penis.

  The Deep Artery of the Penis (a. profunda penis; artery to the corpus cavernosum), one of the terminal branches of the internal pudendal, arises from that vessel while it is situated between the two fasciæ of the urogenital diaphragm; it pierces the inferior fascia, and, entering the crus penis obliquely, runs forward in the center of the corpus cavernosum penis, to which its branches are distributed.

  The Dorsal Artery of the Penis (a. dorsalis penis) ascends between the crus penis and the pubic symphysis, and, piercing the inferior fascia of the urogenital diaphragm, passes between the two layers of the suspensory ligament of the penis, and runs forward on the dorsum of the penis to the glans, where it divides into two branches, which supply the glans and prepuce. On the penis, it lies between the dorsal nerve and deep dorsal vein, the former being on its lateral side. It supplies the integument and fibrous sheath of the corpus cavernosum penis, sending branches through the sheath to anastomose with the preceding vessel.

  The internal pudendal artery in the female is smaller than in the male. Its origin and course are similar, and there is considerable analogy in the distribution of its branches. The perineal artery supplies the labia pudendi; the artery of the bulb supplies the bulbus vestibuli and the erectile tissue of the vagina; the deep artery of the clitoris supplies the corpus cavernosum clitoridis; and the dorsal artery of the clitoris supplies the dorsum of that organ, and ends in the glans and prepuce of the clitoris.

  The inferior gluteal artery (a. glutæa inferior; sciatic artery), the larger of the two terminal branches of the anterior trunk of the hypogastric, is distributed chiefly to the buttock and back of the thigh. It passes down on the sacral plexus of nerves and the Piriformis, behind the internal pudendal artery, to the lower part of the greater sciatic foramen, through which it escapes from the pelvis between the Piriformis and Coccygeus. It then descends in the interval between the greater trochanter of the femur and tuberosity of the ischium, accompanied by the sciatic and posterior femoral cutaneous nerves, and covered by the Glutæus maximus, and is continued down the back of the thigh, supplying the skin, and anastomosing with branches of the perforating arteries.

  Inside the pelvis it distributes branches to the Piriformis, Coccygeus, and Levator ani; some branches which supply the fat around the rectum, and occasionally take the place of the middle hemorrhoidal artery; and vesical branches to the fundus of the bladder, vesiculæ seminales, and prostate. Outside the pelvis it gives off the following branches:

Muscular.

Anastomotic.

Coccygeal.

Articular.

Comitans Nervi Ischiadici.

Cutaneous.

 

  The Muscular Branches supply the Glutæus maximus, anastomosing with the superior gluteal artery in the substance of the muscle; the external rotators, anastomosing with the internal pudendal artery; and the muscles attached to the tuberosity of the ischium, anastomosing with the posterior branch of the obturator and the medial femoral circumflex arteries.

  The Coccygeal Branches run medialward, pierce the sacrotuberous ligament, and supply the Glutæus maximus, the integument, and other structures on the back of the coccyx.

  The Arteria Comitans Nervi Ischiadici is a long, slender vessel, which accompanies the sciatic nerve for a short distance; it then penetrates it, and runs in its substance to the lower part of the thigh.

  The Anastomotic is directed downward across the external rotators, and assists in forming the so-called crucial anastomosis by joining with the first perforating and medial and lateral femoral circumflex arteries.

  The Articular Branch, generally derived from the anastomotic, is distributed to the capsule of the hip-joint.

  The Cutaneous Branches are distributed to the skin of the buttock and back of the thigh.

  The iliolumbar artery (a. iliolumbalis) a branch of the posterior trunk of the hypogastric, turns upward behind the obturator nerve and the external iliac vessels, to the medial border of the Psoas major, behind which it divides into a lumbar and an iliac branch.

  The Lumbar Branch (ramus lumbalis) supplies the Psoas major and Quadratus lumborum, anastomoses with the last lumbar artery, and sends a small spinal branch through the intervertebral foramen between the last lumbar vertebra and the sacrum, into the vertebral canal, to supply the cauda equina.

  The Iliac Branch (ramus iliacus) descends to supply the Iliacus; some offsets, running between the muscle and the bone, anastomose with the iliac branches of the obturator; one of these enters an oblique canal to supply the bone, while others run along the crest of the ilium, distributing branches to the gluteal and abdominal muscles, and anastomosing in their course with the superior gluteal, iliac circumflex, and lateral femoral circumflex arteries.

  The lateral sacral arteries (aa. sacrales laterales) arise from the posterior division of the hypogastric; there are usually two, a superior and an inferior.

  The superior, of large size, passes medialward, and, after anastomosing with branches from the middle sacral, enters the first or second anterior sacral foramen, supplies branches to the contents of the sacral canal, and, escaping by the corresponding posterior sacral foramen, is distributed to the skin and muscles on the dorsum of the sacrum, anastomosing with the superior gluteal.

 

  The superficial branch enters the deep surface of the Glutæus maximus, and divides into numerous branches, some of which supply the muscle and anastomose with the inferior gluteal, while others perforate its tendinous origin, and supply the integument covering the posterior surface of the sacrum, anastomosing with the posterior branches of the lateral sacral arteries.

  The deep branch lies under the Glutæus medius and almost immediately subdivides into two. Of these, the superior division, continuing the original course of the vessel, passes along the upper border of the Glutæus minimus to the anterior superior spine of the ilium, anastomosing with the deep iliac circumflex artery and the ascending branch of the lateral femoral circumflex artery. The inferior division crosses the Glutæus minimus obliquely to the greater trochanter, distributing branches to the Glutæi and anastomoses with the lateral femoral circumflex artery. Some branches pierce the Glutæus minimus and supply the hip-joint.

 

The external iliac artery 105

 

Branches.—Besides several small branches to the Psoas major and the neighboring lymph glands, the external iliac gives off two branches of considerable size:

Inferior Epigastric.

Deep Iliac Circumflex.

 

  The inferior epigastric artery (a. epigastrica inferior; deep epigastric artery) arises from the external iliac, immediately above the inguinal ligament. It curves forward in the subperitoneal tissue, and then ascends obliquely along the medial margin of the abdominal inguinal ring; continuing its course upward, it pierces the transversalis fascia, and, passing in front of the linea semicircularis, ascends between the Rectus abdominis and the posterior lamella of its sheath. It finally divides into numerous branches, which anastomose, above the umbilicus, with the superior epigastric branch of the internal mammary and with the lower intercostal arteries. As the inferior epigastric artery passes obliquely upward from its origin it lies along the lower and medial margins of the abdominal inguinal ring, and behind the commencement of the spermatic cord. The ductus deferens, as it leaves the spermatic cord in the male, and the round ligament of the uterus in the female, winds around the lateral and posterior aspects of the artery.

 

Branches.—The branches of the vessel are: the external testicular artery (cremasteric artery), which accompanies the spermatic cord, and supplies the Cremaster and other coverings of the cord, anastomosing with the internal testicular artery (in the female it is very small and accompanies the round ligament); a pubic branch which runs along the inguinal ligament, and then descends along the medial margin of the femoral ring to the back of the pubis, and there anastomoses with the pubic branch of the obturator artery; muscular branches, some of which are distributed to the abdominal muscles and peritoneum, anastomosing with the iliac circumflex and lumbar arteries; branches which perforate the tendon of the Obliquus externus, and supply the integument, anastomosing with branches of the superficial epigastric.

 

Peculiarities.—The origin of the inferior epigastric may take place from any part of the external iliac between the inguinal ligament and a point 6 cm. above it; or it may arise below this ligament, from the femoral. It frequently springs from the external iliac, by a common trunk with the obturator. Sometimes it arises from the obturator, the latter vessel being furnished by the hypogastric, or it may be formed of two branches, one derived from the external iliac, the other from the hypogastric.

  The deep iliac circumflex artery (a. circumflexa ilium profunda) arises from the lateral aspect of the external iliac nearly opposite the inferior epigastric artery. It ascends obliquely lateralward behind the inguinal ligament, contained in a fibrous sheath formed by the junction of the transversalis fascia and iliac fascia, to the anterior superior iliac spine, where it anastomoses with the ascending branch of the lateral femoral circumflex artery. It then pierces the transversalis fascia and passes along the inner lip of the crest of the ilium to about its middle, where it perforates the Transversus, and runs backward between that muscle and the Obliquus internus, to anastomose with the iliolumbar and superior gluteal arteries. Opposite the anterior superior spine of the ilium it gives off a large branch, which ascends between the Obliquus internus and Transversus muscles, supplying them, and anastomosing with the lumbar and inferior epigastric arteries.

 

The common iliac veins arose on level of sacroiliac joint by the confluence of internal iliac vein and external iliac vein.

Internal iliac vein has parietal and visceral influxes according to ramification of same name arteries.

Visceral tributaries of internal iliac vein form from such venous plexuses:

·          sacral venous plexus;

·          vesical venous plexus;

·          rectal venous plexus.

External iliac vein is continuation of femoral vein and receives blood from all veins of lower limb. Inferior epigastric vein and deep circumflexа ilei vein empties into external iliac vein under inguinal ligament.

  The external iliac vein (v. iliaca externa), the upward continuation of the femoral vein, begins behind the inguinal ligament, and, passing upward along the brim of the lesser pelvis, ends opposite the sacroiliac articulation, by uniting with the hypogastric vein to form the common iliac vein. On the right side, it lies at first medial to the artery: but, as it passes upward, gradually inclines behind it. On the left side, it lies altogether on the medial side of the artery. It frequently contains one, sometimes two, valves.

 

Tributaries.—The external iliac vein receives the inferior epigastric, deep iliac circumflex, and pubic veins.

  The Inferior Epigastric Vein (v. epigastrica inferior; deep epigastric vein) is formed by the union of the venæ comitantes of the inferior epigastric artery, which communicate above with the superior epigastric vein; it joins the external iliac about 1.25 cm. above the inguinal ligament.

  The Deep Iliac Circumflex Vein (v. circumflexa ilium profunda) is formed by the union of the venæ comitantes of the deep iliac circumflex artery, and joins the external iliac vein about 2 cm. above the inguinal ligament.

  The Pubic Vein communicates with the obturator vein in the obturator foramen, and ascends on the back of the pubis to the external iliac vein.

  The hypogastric vein (v. hypogastrica; internal iliac vein) begins near the upper part of the greater sciatic foramen, passes upward behind and slightly medial to the hypogastric artery and, at the brim of the pelvis, joins with the external iliac to form the common iliac vein.

 

The veins of the right half of the male pelvis.

 

  2. The Inferior Gluteal Veins (vv. glutaeæ inferiores; sciatic veins), or venæ comitantes of the inferior gluteal artery, begin on the upper part of the back of the thigh, where they anastomose with the medial femoral circumflex and first perforating veins. They enter the pelvis through the lower part of the greater sciatic foramen and join to form a single stem which opens into the lower part of the hypogastric vein.

  3. The Internal Pudendal Veins (internal pudic veins) are the venæ comitantes of the internal pudendal artery. They begin in the deep veins of the penis which issue from the corpus cavernosum penis, accompany the internal pudendal artery, and unite to form a single vessel, which ends in the hypogastric vein. They receive the veins from the urethral bulb, and the perineal and inferior hemorrhoidal veins. The deep dorsal vein of the penis communicates with the internal pudendal veins, but ends mainly in the pudendal plexus.

 

Scheme of the anastomosis of the veins of the rectum.

 

  4. The Obturator Vein (v. obturatoria) begins in the upper portion of the adductor region of the thigh and enters the pelvis through the upper part of the obturator foramen. It runs backward and upward on the lateral wall of the pelvis below the obturator artery, and then passes between the ureter and the hypogastric artery, to end in the hypogastric vein.

  5. The Lateral Sacral Veins (vv. sacrales laterales) accompany the lateral sacral arteries on the anterior surface of the sacrum and end in the hypogastric vein.

  6. The Middle Hemorrhoidal Vein (v. hæmorrhoidalis media) takes origin in the hemorrhoidal plexus and receives tributaries from the bladder, prostate, and seminal vesicle; it runs lateralward on the pelvic surface of the Levator ani to end in the hypogastric vein.

  The hemorrhoidal plexus (plexus hæmorrhoidalis) surrounds the rectum, and communicates in front with the vesical plexus in the male, and the uterovaginal plexus in the female. It consists of two parts, an internal in the submucosa, and an external outside the muscular coat. The internal plexus presents a series of dilated pouches which are arranged in a circle around the tube, immediately above the anal orifice, and are connected by transverse branches.

  The lower part of the external plexus is drained by the inferior hemorrhoidal veins into the internal pudendal vein; the middle part by the middle hemorrhoidal vein which joins the hypogastric vein; and the upper part by the superior hemorrhoidal vein which forms the commencement of the inferior mesenteric vein, a tributary of the portal vein. A free communication between the portal and systemic venous systems is established through the hemorrhoidal plexus.

  The veins of the hemorrhoidal plexus are contained in very loose, connective tissue, so that they get less support from surrounding structures than most other veins, and are less capable of resisting increased blood-pressure.

  The pudendal plexus (plexus pudendalis; vesicoprostatic plexus) lies behind the arcuate public ligament and the lower part of the symphysis pubis, and in front of the bladder and prostate. Its chief tributary is the deep dorsal vein of the penis, but it also receives branches from the front of the bladder and prostate. It communicates with the vesical plexus and with the internal pudendal vein and drains into the vesical and hypogastric veins. The prostatic veins form a well-marked prostatic plexus which lies partly in the fascial sheath of the prostate and partly between the sheath and the prostatic capsule. It communicates with the pudendal and vesical plexuses.

  The vesical plexus (plexus vesicalis) envelops the lower part of the bladder and the base of the prostate and communicates with the pudendal and prostatic plexuses. It is drained, by means of several vesical veins, into the hypogastric veins.

  The Dorsal Veins of the Penis (vv. dorsales penis) are two in number, a superficial and a deep. The superficial vein drains the prepuce and skin of the penis, and, running backward in the subcutaneous tissue, inclines to the right or left, and opens into the corresponding superficial external pudendal vein, a tributary of the great saphenous vein. The deep vein lies beneath the deep fascia of the penis; it receives the blood from the glans penis and corpora cavernosa penis and courses backward in the middle line between the dorsal arteries; near the root of the penis it passes between the two parts of the suspensory ligament and then through an aperture between the arcuate pubic ligament and the transverse ligament of the pelvis, and divides into two branches, which enter the pudendal plexus. The deep vein also communicates below the symphysis pubis with the internal pudendal vein.

  The uterine plexuses lie along the sides and superior angles of the uterus between the two layers of the broad ligament, and communicate with the ovarian and vaginal plexuses. They are drained by a pair of uterine veins on either side: these arise from the lower part of the plexuses, opposite the external orifice of the uterus, and open into the corresponding hypogastric vein.

  The vaginal plexuses are placed at the sides of the vagina; they communicate with the uterine, vesical, and hemorrhoidal plexuses, and are drained by the vaginal veins, one on either side, into the hypogastric veins.

 

Vessels of the uterus and its appendages, rear view.

 

Peculiarities.—The left common iliac vein, instead of joining with the right in its usual position, occasionally ascends on the left side of the aorta as high as the kidney, where, after receiving the left renal v

ein, it crosses over the aorta, and then joins with the right vein to form the vena cava. In these cases, the two common iliacs are connected by a small communicating branch at the spot where they are usually united.

 

Prepared by

Reminetskyy B.Y.