Ovary-Function-Position of the Ovary-Cysts of the Ovary-

Ovary

the ovary is oval shaped, measuring 1.5 × 0.75 in. (4 × 2 cm), and is attached to the back of the broad ligament by the mesovarium.

That part of the broad ligament extending between the attachment of the mesovarium and the lateral wall of the pelvis is called the suspensory ligament of the ovary. The round ligament of the ovary, which represents the remains of the upper part of the gubernaculum, connects the lateral margin of the uterus to the ovary.

The ovary usually lies against the lateral wall of the pelvis in a depression called the ovarian fossa, bounded by the external iliac vessels above and by the internal iliac vessels behind. The position of the ovary is, however, extremely variable, and it is often found hanging down in the rectouterine pouch (pouch of Douglas). During pregnancy, the enlarging uterus pulls the ovary up into the abdominal cavity. After childbirth, when the broad ligament is lax, the ovary takes up a variable position in the pelvis. The ovaries are surrounded by a thin fibrous capsule, the tunica albuginea. This capsule is covered externally by a modified area of peritoneum called the germinal epithelium.

The term germinal epithelium is a misnomer because the layer does not give rise to ova. Oogonia develop before birth from primordial germ cells. Before puberty, the ovary is smooth, but after puberty, the ovary becomes progressively scarred as successive corpora lutea degenerate. After menopause, the ovary becomes shrunken and its surface is pitted with scars.

Function

The ovaries are the organs responsible for the production of the female germ cells, the ova, and the female sex hormones, estrogen and progesterone, in the sexually mature female.

Position of the Ovary

The ovary is kept in position by the broad ligament and the mesovarium. After pregnancy, the broad ligament is lax, and the ovaries may prolapse into the rectouterine pouch (pouch of Douglas). In these circumstances, the ovary may be tender and cause discomfort on sexual intercourse (dyspareunia). An ovary situated in the rectouterine pouch may be palpated through the posterior fornix of the vagina
.

Cysts of the Ovary

Follicular cysts are common and originate in unruptured graafian follicles; they rarely exceed 0.6 in. (1.5 cm) in diameter. Luteal cysts are formed in the corpus luteum. Fluid is retained, and the corpus luteum cannot become fibrosed. Luteal cysts rarely exceed 1.2 in. (3 cm) in diameter.

Appendix- Common Positions of the Tip of the Appendix-Blood Supply-Lymph Drainage-Nerve Supply-Variability of Position of the Appendix-Why the Infection of the Appendix is very common-Pain of Appendicitis-Perforation of the Appendix

Appendix

Description

The appendix is a narrow, muscular tube containing a large amount of lymphoid tissue. It varies in length from 3 to 5 in. (8 to 13 cm). The base is attached to the posteromedial surface of the cecum about 1 in. (2.5 cm) below the ileocecal junction. The remainder of the appendix is free. It has a complete peritoneal covering, which is attached to the mesentery of the small intestine by a short mesentery of its own, the mesoappendix. The mesoappendix contains the appendicular vessels and nerves. The appendix lies in the right iliac fossa, and in relation to the anterior abdominal wall its base is situated one third of the way up the line joining the right anterior superior iliac spine to the umbilicus (McBurney’s point). Inside the abdomen, the base of the appendix is easily found by identifying the teniae coli of the cecum and tracing them to the base of the appendix, where they converge to form a continuous longitudinal muscle coat.




Common Positions of the Tip of the Appendix

 The tip of the appendix is subject to a considerable range of movement and may be found in the following positions:
(a) coiled up behind the cecum,
(b) hanging down into the pelvis against the right pelvic wall,
(c) projecting upward along the lateral side of the cecum,
 and (d) in front of or behind the terminal part of the ileum. The first and second positions are the most common sites

Blood Supply

Arteries The appendicular artery is a branch of the posterior cecal artery.

Veins The appendicular vein drains into the posterior cecal vein.

Lymph Drainage

The lymph vessels drain into one or two nodes lying in the mesoappendix and then eventually into the superior mesenteric nodes.

Nerve Supply

The appendix is supplied by the sympathetic and parasympathetic(vagus) nerves from the superior mesenteric plexus. Afferent nerve fibers concerned with the conduction of visceral pain from the appendix accompany the sympathetic nerves and enter the spinal cord at the level of the 10th thoracic segment.

Variability of Position of the Appendix

when attempting to diagnose an appendicitis The inconstancy of the position of the appendix should be borne in mind. A retrocecal appendix, for example, may lie behind a cecum distended with gas, and thus it may be difficult to elicit tenderness on palpation in the right iliac region. Irritation of the psoas muscle, conversely, may cause the patient to keep the right hip joint flexed. An appendix hanging down in the pelvis may result in absent abdominal tenderness in the right lower quadrant, but deep tenderness may be experienced just above the symphysis pubis. Rectal or vaginal examination may reveal tenderness of the peritoneum in the pelvis on the right side.

 

Why the Infection of the Appendix is very common
?

The following factors contribute to the appendix’s predilection to infection:

■■ It is a long, narrow, blind-ended tube, which encourages stasis of large-bowel contents.

■■ It has a large amount of lymphoid tissue in its wall.

■■ The lumen has a tendency to become obstructed by hardened intestinal contents (enteroliths), which leads to further stagnation of its contents
.

Pain of Appendicitis

the pain of the appendix is produced by distention of its lumen or spasm of its muscle. The afferent pain fibers enter the spinal cord at the level of the 10th thoracic segment, and a vague referred pain is felt in the region of the umbilicus. Later, the pain shifts to where the inflamed appendix irritates the parietal peritoneum. Here the pain is precise, severe, and localized

Perforation of the Appendix

The appendix is supplied by a long small closed artery that does not anastomose with other arteries. The blind end of the appendix is supplied by the terminal branches of the appendicular artery. Inflammatory edema of the appendicular wall compresses the blood supply to the appendix and often leads to thrombosis of the appendicular artery. These conditions commonly result in necrosis or gangrene of the appendicular wall, with perforation. Perforation of the appendix or transmigration of bacteria through the inflamed appendicular wall results in infection of the peritoneum of the greater sac.

Rib and Costal Cartilage Identification- Pleural Reflections- Position and Enlargement of the Heart

Rib and Costal Cartilage Identification

When one is examining the chest from in front, the sternal angle is an important landmark. Its position can easily be felt and often be seen by the presence of a transverse ridge. The finger moved to the right or to the left passes directly onto the second costal cartilage and then the 2nd rib. All other ribs can be counted from this point. The 12th rib can usually be felt from behind, but in some obese persons this may prove difficult

Pleural Reflections

It is hardly necessary to emphasize the importance of knowing the surface markings of thepleural reflections and the lobes of the lungs. When listening to the breath sounds of the respiratory tract, it should be possible to have a mental image of the structures that lie beneath the stethoscope. The cervical dome of the pleura and the apex of the lungs extend up into the neck so that at their highest point they lie about 1 in. (2.5 cm) above the clavicle. Consequently, they are vulnerable to stab wounds in the root of the neck or to damage by an anesthetist’s needle when a nerve block of the lower trunk of the brachial plexus is being performed.

Remember also that the lower limit of the pleural reflection, as seen from the back, may be damaged during a nephrectomy. The pleura crosses the 12th rib and may be damaged during removal of the kidney through an incision in the loin

.

Position and Enlargement of the Heart

The surface markings of the heart and the position of the apex beat may enable a physician to determine whether the heart has shifted its position in relation to the chest wall or whether the heart is enlarged by disease. The apex beat can often be seen and almost always can be felt. The position of the margins of the heart can be determined by percussion.