• Normal Heart Anatomy

    • Heart muscle is supplied by the coronary arteries, not by the blood flowing through the heart.
    • The major coronary vessels are the right coronary artery (RCA) and left main coronary artery (LCA), both of which come directly off of the aorta via the coronary ostia.
    • The LCA divides into the left anterior descending artery(LAD) and circumflex artery.
    • The RCA has no major branches, and terminates as the posterior descending artery (PDA).
    • There are may be variations in the anatomy.
  • Heart Function

    • The normal heart is really two separate pumps working in tandem; there is no connection between the right and left sides in the normal post-fetal heart.
    • The right heart receives de-oxygenated blood from the body, moving it from the right atrium to the right ventricle to the lungs via the pulmonary artery. Carbon dioxide is released and oxygen is picked up in the lungs.
    • The left heart receives oxygenated blood from the lungs, moving it from the left atrium to the left ventricle, and from there to the aorta, which distributes it to the rest of the body.
    • The ventricles are thick muscular chambers which move blood with each contraction; the average left ventricle contracts with a force of 120 mmHg.
  • Coronary Artery Anatomy

    • Right heart dominance: the posterior portion of the interventricular septum is supplied by the posterior descending branch of the right coronary artery.
    • Left heart dominance: the entire septum is supplied by branches of the left anterior descending artery; an obstruction in that vessel may lead to loss of the entire septum, an often fatal event. The posterior descending artery is derived from a branch of the circumflex artery instead of from the RCA.
  • Normal Valve Function

    • Also known as the left atrioventricular valve, the mitral valve has 2 leaflets which are anchored to the ventricle floor by papillary muscles and chordae tendinae, as are the leaflets of the right atrioventricular valve (tricuspid valve).
    • The aortic and pulmonary (pulmonic) valves are semilunar valves, and have thin cusps with thickened edges which seal during diastole (when the ventricles are relaxed and blood flows into the atria).
    • The mitral valve prevents backflow from the left ventricle into the atrium; minor mitral valve prolapse or leak is usually clinically insignificant.
  • Pulmonary Embolism

    • A pulmonary embolism is a blockage in one or more arteries of the lungs. In most cases, it is caused by clots that travel to the lungs from another part of the body, most commonly from a DVT in a lower extremity.
    • Depending on the size of the embolus, it can occlude the main pulmonary artery, straddle the arterial bifurcation, or dis- seminate out into the smaller branching arteries of the lungs.
    • Saddle embolisms are frequently fatal, while embolic showers can be clinically silent unless they block enough of the pulmonary vasculature.
  • The Aorta and Its Branches

    • The largest artery in the body, the aorta leaves the left ventricle and supplies all of the body’s tissues, including the heart itself, via its branches.
    • The major parts are the arch (from the aortic valve to the left subclavian artery), descending thoracic aorta (from the left subclavian to the diaphragm) and abdominal aorta (from the diaphragm to the iliac bifurcation at about the level of the umbilicus).
    • There are three major vessels leaving the arch and these supply the head, neck and arms; there are segmental vessels supplying the body wall throughout the length of the aorta. Major branches supply abdominal structures; the iliac arteries and their branches supply the pelvis and legs.
  • Electrocardiography

    • A tracing is made from electrical impulses traveling through the heart, tracking the way the heart muscle reacts to the conduction system.
    • An electrical impulse is initiated at the sinoatrial node, passes through specialized neuromuscular fibers lying beneath the inner lining of the heart until it reaches the atrioventricular node; from there, it travels through the Bundle of His, into the bundle branches and the Purkinje fibers, stimulating ventricular contraction.
    • Changes in tracings are evaluated by comparing them to normal and/or baseline tracings; a physician can get information about areas of heart damage, both acute and chronic.
  • Arterial and Venous Anatomy

    • Although the cardiovascular system is referred to as one unit, it is actually two separate systems which work independently.
    • Through the arterial supply, oxygenated blood is distributed from the lungs to the left heart and aorta, and eventually to within 5 cells of every cell in the body. The arteries divide into smaller arteries, then into arterioles, which in turn divide into capillaries. Oxygen exchange takes place at the level of the capillaries, vessels whose walls are only one cell thick.
    • In the venous system, deoxygenated blood drains from the capillaries, which conjoin into venules, small veins, veins, and the major draining vessels – the superior and inferior venae cavae. This blood then enters the right heart and travels to the lungs to re- oxygenate and start the cycle again.
  • Cancer Metastasis

    • Cancer tends to spread by two mechanisms: infiltration, in which the tumor pushes against and enters contiguous tissue; and metastasis, when cancer cells enter lymphatic channels and/or small blood vessels and eventually travel to distant locations and organs in the body.
    • Certain tumors have a predilection for specific sites. Colon cancer frequently spreads to the liver, and breast cancer to the brain and spine.
    • When there is lymphatic spread, the local and regional lymph nodes are the first line of defense; when the nodes fill up with dividing tumor cells, the cells then break free and travel toward the heart for distribution throughout the body.
  • Lead-Time Bias

    • A common assumption is that a cancer may not have been diagnosed early enough to make a difference, with the assumption being that early diagnosis is always better.
    • In reality, cancers are present for very long periods of time before they are diagnosable, and many have metastasized prior to the period in which they can be detected.
    • The life span of more than 60% of cancer patients is essentially predetermined by the characteristics of the cancer itself. While a patient diagnosed earlier may live “longer” than one diagnosed later, both patients actually survive about the same length of time from the first cancer cell.
  • Breast Anatomy

    • The breast in a premenopausal woman is composed of glandular tissue, fat, connective tissue and ducts; the axillary tail of breast tissue is tucked upward in the axilla. The breast lies on the pectoralis muscles of the thorax.
    • The breast is divided by irregular fibrous septa which prevent masses from migrating from one area of the breast to another; malignant tumors may eventually erode through these septa.
    • Lymphatic channels travel throughout the breast, with all but the most medial portions draining to the axillary lymph nodes. The “sentinel” node—the first node to receive drainage from the breast—can be determined with testing and evaluated for metastatic spread.
    • Post-menopausal women have little glandular tissue since most of it has been replaced by fat.
  • Mammography

    • Mammography is an imaging technique which allows visualization of breast tissue. Fat, glandular tissue and ductal tissue have characteristic densities and patterns.
    • Solid tumors are generally easier to see in older patients with larger amounts of fat within the breasts, but can be difficult to see in patients with “dense” breasts (young women and women with fibrocystic breasts).
    • Approximately 75% of breast cancers can be seen on mammography, with the patient’s breast characteristics being the largest determining factor.
    • Like in the arm, the deep, muscular arteries of the leg travel together, but the superficial veins are unpaired and variable in course.
    • The legs receive blood from the terminal branches of the aorta, the iliac arteries. Branches supply the muscles of the thigh, and the name of the artery changes as it passes certain landmarks.
    • The major vessels trifurcate behind the knee, dividing into the anterior and posterior tibial arteries and the peroneal artery, all of which travel toward the feet supplying the muscles and other tissues along the way.
    • As in the arm, there are connective vascular arches in the foot supplying collateral circulation.
  • Blood Supply to the Brain

    • The anterior 2/3 of the brain is supplied by branches of the internal carotid artery, whose terminal branches form the anterior and middle cerebral arteries.
    • The vertebral arteries branch off the subclavian arteries and through small openings in the transverse processes of the cervical vertebrae. They merge to form the basilar artery supplying the cerebellum, brain stem, and the posterior cerebrum via the posterior cerebral arteries.
    • The Circle of Willis has small connecting vessels between the three major cerebral vessels. Blood can change direction within the circle for collateral blood flow if needed. There can be significant variation in the form of the Circle of Willis from one individual to another.
    • Tissues supplied by the tiny terminal branches of vessels are known as watershed regions and are vulnerable to damage during periods of low perfusion or oxygenation.
  • Aortic Dissection

    • Sometimes called “dissecting aneurysm”, this is not an aneurysm, but a separation of the aortic wall layers.
    • Blood enters the aortic wall through a small tear in the intima or inner lining of the artery. Under pressure, it then dissects through the wall, creating a false lumen or false channel. Sometimes there is a second tear through which the blood re-enters the true aortic lumen; sometimes the blood breaks through the wall to the thorax or retroperitoneal spaces.
    • Dissections are usually associated with hypertension and atherosclerosis, although certain genetic conditions (Marfan’s syndrome) can predispose to dissection.
    • Symptoms include a severe tearing pain in the back as the dissection travels distally, changes in blood pressure and distal pulses, and loss of various physiologic functions if the dissection blocks the blood supply to major organs.
  • Deep Vein Thrombosis

    • These potentially lethal blood clots usually form in the deep veins of the leg or in the pelvis. Those in the legs are usually painful, whereas those in the pelvis may be asymptomatic.
    • The clots usually form in the valves of the larger veins, propagating upward toward the heart.
    • Clots of any size can break off and travel with the blood flow through the inferior vena cava to the right side of the heart and to the lungs; the pulmonary vasculature acts like a sieve and clots get caught in the vessels as the vessels get smaller, causing loss of blood flow in those areas. These clots are known as pulmonary emboli if they reach the lungs.
    • Conditions associated with DVT and PE include a history of leg trauma, cancer, surgery, venous stasis from illness, lack of exercise, clotting defects and others.
  • Atherosclerosis

    • Atherosclerotic plaque is fatty, cholesterol-laden material which accumulates within the inner layer of the major arteries, narrowing the diameter of the lumen or opening.
    • It can occur in any artery in the body and is a direct cause of stroke when in the carotid arteries; myocardial infarction when in the coronary arteries; acute bowel ischemia when in the mesenteric vessels; peripheral vascular disease when in vessels to the legs, etc.
    • Atherosclerosis can result in increased blood pressure in an effort to overcome the higher pressures caused by arterial stenosis throughout the body.
  • Balloon Angioplasty

    • This procedure is a relatively non-invasive technique of opening stenotic blood vessels.
    • A catheter is threaded through the arterial system from the arm or leg and into the diseased artery. The balloon is then positioned inside the stenotic area and gently inflated several times to crush the plaque and flatten it against the walls of the vessel.
    • This procedure is commonly performed and is often accompanied by the deployment of a stent to hold the vessel open.
    • Complications can include clot formation on the fractured plaque after the release of clotting factors and formation of a dissection (sometimes incorrectly called a “dissecting aneurysm”) in the vessel wall.
  • CABG

    • When coronary arteries are significantly blocked (>70% stenosis), pain symptoms often occur with exercise in the form of stable angina, or at rest in the form of unstable angina.
    • Bypass vessels are harvested as free grafts from the saphenous veins of the legs. These are anastomosed to the aorta and then to the coronary arteries, literally bypassing the blocked regions.
    • The internal mammary arteries, which lie on either side of the sternum within the rib cage, can also be harvested and anastomosed directly to the coronary arteries. These grafts are less likely to stenose than are vein grafts.
    • The procedure can be performed either on or off cardiopulmonary bypass.
  • Fetal/Neonatal Circulation

    • Heart muscle is supplied by the coronary arteries, not by the blood flowing through the heart.
    • The major coronary vessels are the right coronary artery (RCA) and left main coronary artery (LCA), both of which come directly off of the aorta via the coronary ostia.
    • The LCA divides into the left anterior descending artery(LAD) and circumflex artery.
    • The RCA has no major branches and terminates as the posterior descending artery (PDA).
    • There are may be variations in the anatomy.
  • Mandibular Anatomy

    • The mandible, or lower jaw, is the bone that hinges to the skull and, together with the maxilla, forms the mouth.
    • The mandibular nerve, the third and largest branch of the trigeminal nerve, runs along the mandible.
    • The mandibular nerve has both sensory and motor functions. It divides into trunks and smaller branches to innervate the teeth and gums of the mandible, the lower lip and lower part of the face, and the muscles of mastication.
  • Normal Dentition

    • There are normally 32 teeth, divided into 4 categories: molars, premolars, canines, and incisors.
    • The teeth are embedded in the bones of the maxilla (upper jaw) and mandible (lower jaw) and are held in position by periodontal ligaments.
    • The third molars (teeth #1, 16, 17, 32) are often vestigial and/or impacted. These are commonly known as “wisdom teeth”.
    • The roots of the teeth are anchored within the bone and contain an artery, vein, and nerve which travel to the main portion of the tooth and divide within the pulp.
    • Dentin covers the pulp and very hard enamel covers the dentin; the bone is covered with a mucosal tissue, the gingiva.
  • Anatomy of the Ear

    • The external ear acts as a collecting device for sound waves, focusing them into the canal.
    • External sound waves cause vibration of the tympanic membrane (ear drum). The vibrating membrane moves the three ossicles of the middle ear (malleus, incus, and stapes) which transfer the vibration to branches of the vestibulocochlear nerve (cranial nerve VIII) within the cochlea.
    • Motion and balance are detected by three fluid-filled canals in the temporal bone. Oriented in three perpendicular planes, the canals contain tiny hair cells that pick up fluid movement with motion of the head. This information is transmitted through the vestibular portions of the nerve to the appropriate portions of the brain.
  • Gastric Bypass

    • Gastric bypass is performed to reduce the volume of food which the stomach can hold, and to reduce the amount of bowel available to absorb nutrients.
    • There are several surgical variations; in this version, the stomach is divided and the small bowel is surgically joined to the small stomach remnant, bypassing the rest of the stomach. A second surgical anastomosis is made further down the length of the small bowel. No tissue is removed.
    • The procedure can be performed either through a large abdominal incision or laparoscopically, using “band-aid” incisions. A lighted scope is inserted into the abdomen, as are several slender tubes. Instrumentation is then placed into the tubes and the procedure is performed under direct vision through the scope.
  • Ileus

    • Normal small bowel function is in the form of peristalsis, regular wave-like contractions of the smooth muscle within the wall of the bowel. Digested food materials (chyme) move through the small bowel, where intestinal villi absorb nutrients. These raw materials enter the bloodstream and are distributed throughout the body for growth and maintenance.
    • Ileus is a temporary reduction or cessation of peristalsis, allowing fluid, chyme, and gases to accumulate. It is characterized by abdominal distension and discomfort; on x-ray, distended bowel loops with air/fluid levels can be seen. Bowel sounds are reduced or absent, and gas and stool are not passed.
    • Ileus is a common sequela of abdominal or pelvic surgery, lasting hours to days. Symptoms are relieved by nasogastric suction to reduce pressure.
  • Cholangiography

    • Performed during surgery for gallbladder removal, this is an effective intraoperative radiographic test to look for either blockage or leakage in the biliary tree.
    • This test may be performed prior to removing the gallbladder, or at any time a problem is suspected. A tiny catheter is threaded through a small incision in the cystic duct. Dye is injected into the biliary tract and x-rays are taken, allowing the surgeon to see which ducts are patent. Voids represent stones or tumors, and extravasation represents a leak in the system.
    • While this test is very reliable in the case of a retained stone or suspected damage, the outcome in patients having routine intraoperative cholangiography without apparent complication is the same as those in whom the test was not performed.
  • Lap Chole: Procedure

    • After placement of the trocars, the gallbladder is grasped and retracted upward and outward. Adhesions, connective tissue, and the lesser omentum are divided from the neck of the gallbladder in a medial direction, to reveal a portion of the cystic duct.
    • Clips are placed on the exposed cystic duct and an incision is made between the clips.
    • The cystic artery is then located within the Triangle of Calot (formed by the planes of the lower border of the liver, the cystic duct, and the common hepatic duct), ligated and divided.
    • The gallbladder is removed through one of the ports.
  • Lap Chole: Surgical Set-up

    • Cholecystitis, or inflammation of the gallbladder, is usually caused by gallstones blocking the cystic duct. Removal is usually performed via a laparoscopic approach, using an endoscope for visualization and hollow trocars holding the small instruments used for the surgery.
    • The view through the laparoscope is transmitted to a video monitor, and the physician controls the progress by either looking directly through the scope or at the video display, depending on his or her preference and training.
    • The overall complication rate for the laparoscopic procedure is about half that of the open procedure, although converting a laparoscopic procedure to an open one occurs approximately 4% of the time, usually because of difficulty in visualization.
  • Retroperitoneum

    • Most of the abdominal contents lie within the peritoneum, a sac made up of a sheet of dense connective tissue. Some structures lie behind the peritoneum (retroperitoneal). Others go in and out of it, although edges are sealed and there is little or no direct connection between the intra- and retroperitoneal regions.
    • The liver has a “bare area” at its top where it lies directly against the lower surface of the diaphragm, but the rest of it is intraperitoneal. The ascending and descending colons are both retroperitoneal, while the transverse colon and part of the sigmoid are intraperitoneal; the duodenum, or first portion of the small intestine, is retroperitoneal.
    • True retroperitoneal structures include the pancreas, the kidneys, ureters and adrenals, the great vessels and the pelvic structures.
  • Adhesions

    • Adhesions are fibrous scars which can form after any disturbance within body cavities and spaces. Inciting events can include surgery, trauma, and inflammation.
    • Within hours of disturbance, thin, filmy strands form between bowel loops and between bowel and peritoneum and/or body wall. These continue to form for a period of time and mature over a period of weeks.
    • Mature adhesions are dense, white fibrous tissues which have merged with the outer layer of the tissues; they eventually develop their own blood supply and may become severe enough to cause chronic pain and pose a chronic risk of small bowel obstruction or volvulus.


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