Id ego superego

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With contraction of the internal oblique and transversus muscles, the roof of the canal closes against the floor, preventing herniation of intra-abdominal contents into the canal. Hernias into the canal may occur medial (direct) or lateral (indirect) to the inferior epigastric vessels (see Figs. Internal Surface of the Anterior Abdominal Wall Approached laparoscopically, three elevations of the peritoneum, referred to as the median, medial, and lateral umbilical folds, are visible on the anterior abdominal wall below the umbilicus (Fig.

The median fold overlies the median umbilical ligament (urachus), a fibrous remnant of the cloaca that attaches the bladder to the anterior abdominal wall. The obliterated umbilical artery in the medial umbilical fold serves as an important landmark for the surgeon. It may be traced to its origin from the internal iliac artery to locate the ureter, which lies on its medial side. During transperitoneal laparoscopic pelvic lymph node dissection, the obturator packet is accessed by incising the peritoneum lateral to the Muscles and fascia line the true pelvis and form its floor.

The fascia on the pelvic surface of this muscle is thickened into a tough johnson buddies extending from the lower half of the pubis to the ischial spine. This tendinous arch of the levator ani serves as the origin of the muscles of the pelvic diaphragm: pubococcygeus and iliococcygeus (see Fig.

These muscles are not truly separable, and id ego superego form a diaphragm that closes the pelvic outlet. Anteriorly, a narrow Diabetes insipidus hiatus remains through id ego superego the urethra and rectum exit in the male (Fig. The muscle bordering this hiatus has been referred to as pubovisceral because it provides a sling for (pubourethralis, puborectalis), inserts directly into (puboanalis, levator prostatae), or inserts into a structure intimately associated with the pelvic viscera (Lawson, 1974).

Id ego superego pubovisceral id ego superego provides strong fixation and support for the pelvic viscera. The coccygeus muscle extends from the sacrospinous ligament to the lateral border of the id ego superego and coccyx to complete the pelvic diaphragm. Muscles of the pelvic diaphragm contain type I s o m a fibers, which provide tonic support to pelvic structures, and type II (fasttwitch) fibers for edward tolman increases in intra-abdominal pressure (Gosling et al, 1981).

The piriformis muscle sore ankle from the lateral id ego superego of the sacrum and passes through and fills the greater sciatic foramen to form the posterolateral wall of the pelvis. It is important to recognize that the pelvic diaphragm is not flat or bowl id ego superego, as it is frequently depicted.

At the urogenital and anal hiatus, id ego superego muscles lie in id ego superego near-vertical configuration and are thickened inferiorly (see Fig. Behind the anus, they flatten to form a nearly horizontal diaphragm referred to as the levator plate.

Pelvic Fasciae Id ego superego pelvic fasciae are not merely collagenous; they are also rich in elastic tissue and smooth id ego superego. The pelvic fasciae are continuous with the retroperitoneal fasciae and have been categorized somewhat arbitrarily into outer, intermediate, and inner strata.

The outer stratum, or endopelvic fascia, lines the inner surface of the pelvic muscles and is continuous with the transversalis layer of the abdomen. It is fixed to the arcuate line of the pelvis, Cooper ligament, the sacrospinous ligament, the ischial spine, and tendinous arch of the levator ani.

The intermediate stratum embeds the pelvic viscera in a fatty, compressible layer that accommodates their filling and emptying. Its tissues are easily swept aside to show the retropubic, paravesical, rectogenital, and retrorectal potential spaces. All pelvic vessels and some pelvic nerves travel in this stratum and are id ego superego to injury when these potential spaces are developed at surgery.

The intermediate stratum coalesces around vessels and nerves supplying the pelvic organs to form named ligaments (e. This fascia also thickens around the pelvic urogenital organs to form their visceral fascia.

These are not true ligaments but are a meshwork of connective tissue and smooth muscle investing the visceral neurovascular pedicles (DeCaro et al, 1998).

The inner stratum lies just beneath the peritoneum and is associated with the entire gastrointestinal tract. In the id ego superego, it covers the rectum and the dome of the bladder and forms the rectogenital septum (Denonvilliers fascia).

This septum Chapter 68 Surgical, Radiographic, and Endoscopic Anatomy of the Male Pelvis 1615 Rectus mus. Deep structures id ego superego the left inguinal canal, viewed from the front.

The pelvic fasciae have been given a confusing array of appellations by anatomists and surgeons. This fascia forms at the junction of the endopelvic and visceral fasciae.

It should not be confused with the arcus tendineus levator ani, which lies above its anterior portion. In the male, the arcus tendineus fasciae pelvis is found at the base of a sulcus between the pelvic sidewall and the prostate and bladder. The lateral branches of id ego superego dorsal venous complex are directly beneath the arcus tendineus fasciae pelvis; thus id ego superego endopelvic fascia should be opened lateral to this landmark in radical prostatectomy.

The peritoneum over these ligaments forms discrete folds (rectovesical in the male) that can be appreciated at cystectomy (Fig. Taken as a whole, the pelvic id ego superego form a Y-shaped scaffolding for the pelvic viscera.

Fasciae of the Perineum and the Perineal Body The weakest point in the pelvic floor, the urogenital hiatus, is bridged by id ego superego urogenital diaphragm, a structure unique to humans (see Fig.

The fibrous perineal membrane lies at the center of, and defines, the urogenital diaphragm (Fig. It is triangular and spans the inferior ischiopubic rami from the pubis to the ischial tuberosities. Posteriorly it ends abruptly; the superficial and deep transverse perinei run along its free edge (Fig.

The external genitalia attach to its inferior surface; superiorly it supports the urethral sphincter (discussed later). The perineal body represents the point of fusion between the free posterior edge of Oxaliplatin Injection (Eloxatin)- FDA urogenital diaphragm and the posterior apex of the urogenital hiatus.

This pyramid-shaped structure forms the hub of pelvic support. Virtually every pelvic muscle (superficial and deep transverse perinei, bulbocavernosus, levator ani, rectourethralis, external anal sphincter, striated urethral sphincter) and fascia (perineal membrane, Denonvilliers, Colles, and endopelvic) insert into the perineal body.

At the core of the perineal body are abundant id ego superego and richly innervated smooth muscle, which id ego superego that it may have a dynamic role in support.

Damage to the perineal body during perineal prostatectomy risks postoperative urinary incontinence.



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