Abdomen & Pelvis Gross.medcom

8/17/2019 Abdomen & Pelvis Gross.medcom

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ARTERIAL SUPPLY OF ABDOMEN &PELVIS

AnterolateralAbdominal

Wall

Cutaneous Arteries ( Deep & super!ia" #$%Mus!u"op'reni! Arter$Origin:

Internal thoracic arteryDistribution: (a) Superfcial & deep abdominal wall o hypochondriac region.(b) Anterolateral diaphragm.

)Superior epi*astri! arter$ Origin: Internal thoracic artery Distribution:(a) Rectus abdominis muscle (b) Superfcial & deep abdominal wall o epigastric & upperumbilical regions.

+%,t' & %%t' posterior inter!osta"s arteries$Origin:AortaDistribution:(a).Superfcial & eep abdominal wall o lateral region.

-Su.!osta" Arter$Origin:AortaDistribution:(a).Superfcial & deep abdominal wall o lateral region.

/In0erior epi*astri! arter$Origin:!"ternal Iliac arteryDistribution:(a).Rectus Abdominis muscle(b).eep abdominal wall o pubic & inerior umbilical regions.

1Deep !ir!u23e4 i"ia! arter$Origin:!"ternal Iliac arteryDistribution:(a).Iliacus muscle(b).eep abdominal wall o inguinal region

(c).Iliac ossa

5Super!ia" !ir!u23e4 i"ia! arter$Origin:#emoral arteryDistribution:(a).Superfcial abdominal wall o inguinal region & ad$acent anterior


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thigh

6Super!ia" epi*astri! arter$Origin:#emoral arteryDistribution:

(a).Superfcial abdominal wall o pubic & inerior umbilical regions.

%enis (%#Internal pudendal artery gies o' branches which supplythe penis(i) eep artery o penis(ii) orsal artery o %enis(iii) Artery o the bulb o penis.

()##emoral artery gies o' the superfcial e"ternal pudendalartery which supplies the s*in & asciae o penis.

Scrotum + Posterior scrotal branches o the perineal artery, a brancho internal pudendal artery

+ Anterior scrotal branches o deep e"ternal pudendal

artery, a branch o emoral artery+ Cremestaric artery ,a branch o inerior epigastric artery

-estis -esticular artery ( branch o abdominal aorta)!pididymis -esticular artery!sophagus + et gastric artery (branch o celiac trun*)

+ et inerior phrenic arteryStomach Along lesser curvature by

+ et gastric artery(br. o celiac trun*)+ Right gastric artery ( br. o proper hepatic artery)

Along greater curvature by + Right gastro/omental artery(right gastroepiploic artery),

branch o

gastroduodenal artery.+ et gastro/omental artery(let gastroepiploic artery),branch o splenic artery.

Fundus:+ 0/1 short gastric arteries (branches o splenic artery)

uodenum Upto the opening of bile duct:+ Superior pancreaticoduodenal artery ( br.o

gastroduodenal artery)Below the opening of bile duct:+ Inerior pancreaticoduodenal artery (br.o superior

mesenteric artery). 2e$unum &Ileum

Superior mesenteric artery(owest part o ileum is also supplied by Ileocolic artery)

3ecum Anterior & posterior rectal arteries rom the ileocolic artery( 4ranch o superior mesenteric artery)

Appendi" Appendicular artery , branch o ileocolic artery


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Ascendingcolon

• Ileocolic artery + Right colic branches o superior mesenteric arteries

-ransersecolon

Middle colic artery (branch o superior mesenteric artery)

escendin

g colon &sigmoidcolon

+ et colic artery ( br.o inerior mesenteric artery)

+ Sigmoid arteries (br.o Inerior mesenteric artery)

Spleen Splenic artery%ancreas + %ancreatic branches o splenic artery

+ Superior pancreaticoduodenal artery+ Inerior pancreaticoduodenal artery

ier ier receies blood+ 56/507 through hepatic artery+ 10/867 through portal ein

4ile duct + 3ystic artery+ Right phrenic artery+ %osterior superior pancreaticoduodenal artery+ 9astroduodenal artery

9allbladder &cystic duct

3ystic artery ( arise rom right phrenic artery)

:idneys Renal artery diides to orm arious segmental arteries+ Superior segmental artery to Superior segment+ Anterosuperior segmental artery to Anterosuperior

segment+ Anteroinerior segmental artery to antero inerior segment+ Inerior segmental artery to inerior segment+ %osterior segmental artery to posterior segment o the

*idney

;reters + Upper part < Renal artery+ Middle part / (i) -esticular=oarian arteries

(ii) Abdominal aorta (iii) 3ommon iliac arteries

+ Lower part / (i) >esical artery (ii) ?iddle rectal artery (iii) ;terine essels

Suprarenal9land

+ Superior suprarenal arteries (@/8) rom inerior phrenicarteries

+ ?iddle suprarenal arteries (B) rom abdominal aorta• Inerior suprarenal arteries (B rom Renal artery)

;rinarybladder

+ Superior & Inerior esical arteries (branches o anteriortrun* o internal iliac artery) In emales rom uterine & aginal arteries instead oinerior esical.

+ Cbturator & Inerior 9luteal arteries ( additional supply tobladder)

?ale + ;rethral artery arises rom internal pudendal artery


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urethra + orsal penile artery ia circumDe" branches on each side

#emaleurethra

+ Superior esical arteries+ >aginal arteries

Rectum + Superior rectal artery < continuation o ineriormesenteric artery

+ ?iddle rectal arteries < arise rom anterior diision ointernal iliac artery+ ?edian sacral artery < small branch arising rom bac* o

aortaAnal canal Above pectinate line < superior rectal artery

Below pectinate line < Inerior rectal arteryCaries &;terinetubes

+ Carian arteries (arise rom abdominal aorta)+ -ubal branches o uterine arteries ( 4ranch o internal iliac

arteries);terus + ;terine arteries

+ Carian arteries>agina + >agina branch o internal iliac artery

+ In addition+ -he upper part is supplied by ceicoaginal branch o

uterine artery.+ ower part by middle rectal & internal pudendal arteries.

4ranches o these arteries anastomose to orm anterior &posterior midline essels called the vaginal azygos arteries

uctusdeerens

Artery to ductus deerens ( arises rom one o the terminalbranches o superior esical artery but occasionally arises rominerior esical artery)

%rostategland

Supplied by branches rom+ Inerior esical+ ?iddle rectal+ Internal pudendal arteries

+ -hese arteries orm a large outer or subcapsular ple"us,and a small inner or periurethral ple"us. 9reater part ogland is supplied by subcapsular ple"us.

Reerence :..? & 4. chaurasia

VENOUS DRAINA7E OF ABDOMEN& PELVIS

Anterolateral abdominalwall

• >enous drainage passes a.o8e mainly into a!illaryvein via lateral thoracic vein.

+ >enous drainage passes .e"o9 mainly into fe"oralvein via superfcial epigastric & great saphenous vein.

%enis + #uper$cial dorsal vein+ rain prepuce & penile s*in+ Cpen into e"ternal pudendal ein+ Deep dorsal vein+ rains glans penis & corpora caernosa penis+ iide into let & right branches which connect with

internal pudendal ein & enters the prostatic ple"us.Scrotum Scrotal eins accompany the arteries -estis >eins emerging rom the testis & !pididymis orm


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%a"pinifor" venous ple!us, a networ* o 8/B5 eins lyinganterior to the ductus deerens & surrounding the testicularartery in the spermatic cord. -he eins o each pampiniorm ple"us conerge superiorlyorming ri*'t testi!u"ar 8ein which enters in0erior 8ena!a8a & a "e0t testi!u"ar 8ein which enters the "e0t rena"

8ein!pididymis Same as testis.!sophagus -he enous drainage rom the submucosal eins o this part o

esophagus is both to+ Porta" 8enous sste2 through let gastric ein+ Sste2i! 8enous sste2 through esophageal eins

entering the aEygous einStomach >eins o stomach parallel the arteries in position & course

+ Right & let gastric eins drain into hepatic portal ein+ Short gastric eins & let gastroepiploic (gastro/omental)

eins drain into splenic ein which $oins superiormesenteric ein (S?>) to orm hepatic portal ein

+ Right gastroepiploic (gastro/omental) ein empties into

S?>.+ %repyloric ein ascends oer the pylorus to the right

gastric ein.uodenum + Superior pancreaticoduodenal vein < drains into portal

ein+ Inerior pancreaticoduodenal vein < $oins the S?>

2e$unum &Ileum

Superior mesenteric ein (S?>)

3ecum >enous drainage rom cecum Dow through a tributary of#M&' the ileocolic vein

Appendi" S?> (same as cecum)Ascending

colon

S?>

-ransersecolon

S?>

escending& sigmoidcolon

#rom inerior mesenteric ein Splenic ein hepatic portalein.

Spleen Splenic ein%ancreas + Splenic ein

+ Superior mesenteric ein (S?>)+ %ortal ein

ier :epati! sinusoi;s drain into inter"o.u"ar 8eins which $ointo orm su."o.u"ar 8eins which $oin to orm 'epati! 8eins

which drain into in0erior 8ena !a8a (IVC#4ile duct #rom posterior superior pancreaticoduodenal vein to hepatic

portal ein.9all bladder& cysticduct

#rom cystic veins to hepatic portal ein

:idneys Right & !et renal veins Interlobular eins arcuate eins interlobar eins renal einI>3


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;reters + Renal eins+ 9onadal (testicular=oarian) eins.

Suprarenalglands

Suprarena" 8eins+ Right suprarenal ein I>3+ et suprarenal ein $oins inerior phrenic ein drains

into et renal ein.

;rinarybladder >esical enous ple"us which drains into Internal iliac eins

?aleurethra

Anterior uret'raorsal ein o penis internal pudendal ein prostatic enousple"us.Posterior uret'ra%rostatic & esical enous ple"us internal iliac eins.

#emaleurethra

>enous ple"us around urethra esical enous ple"us internalpudendal ein

Rectum + Superior rectal vein < tributeries o this ein arise rominternal rectal enous ple"us.

+ Middle rectal vein < open into internal iliac eins.+ Median sacral vein < $oins let common iliac ein

Anal canal + Internal rectal enous ple"us+ !"ternal rectal enous ple"us+ Anal eins

Caries >eins drainig the oary orm a ine li*e pa"pinifor" ple!usof veins. -he ple"us condenses into a single oarian ein nearpelic inlet. Right ovarian vein drains into inerior ena caa !et ovarian vein drains into let renal ein.

;terinetubes

(ubal veins drain into pampiniorm enous ple"us & uterineenous ple"us.

;terus -he eins orm a ple"us. %le"us drains through ;terine ,oarian & aginal eins into internal iliac eins.

>agina &aginal venous ple!us drains into internal iliac eins.uctusdeerens

&esical venous ple!us which opens into internal iliac eins.

%rostategland

>eins orm a rich ple"us which communicates with esicalple"us & with internal pudendal ein & drains into esical &internal iliac eins.


NERVE SUPPLY OF ABDOMEN &PELVIS

Anterolateralabdominalwall

S*in & muscles o anterolateral abdominal wall are supplied by (horacoabdo"inal )(*+(,,-:

+ 3ontinuation o lower (1th < BBth ) intercostal neres.+ Supply ?uscles o anterolateral abdominal wall &

oerlying s*in. Lateral cutaneous )thoracic- cutaneous branches ) *th ./th -:

+ Supply S*in o right & let hypochondriac regions. #ubcostal )anterior ra"us of (,0-:

+ Supply ?uscles o anterolateral abdominal wall &


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oerlying s*in, superior to iliac crest & inerior toumbilicus.

1liohypogastric 2 1lioinguinal nerves:( terminal branches o anterior ramus o spinal nere B)

+ 1lihypogastric: Supply S*in oerlying iliac crest , upperinguinal & hypogastric regions, internal obliFue &

transerses abdominis muscles.+ 1lioinguinal Supply S*in o lower inguinal region , monspubis, anterior scrotum or labium ma$us & ad$acent medialthigh, inerior most internal obliFue & transersesabdominis.

?uscles o Anterolateralabdominalwall

+ 3!ternal obli4ue -horacoabdominal & subcostal nere.+ 1nternal obli4ue -horacoabdominal & frst lumbar nere+ Tran8ersus a.;o2inis -horacoabdominal & frst lumbar

nere.+ 5ectus abdo"inis: -horacoabdominal neres.

%enis #ensory nerve supply sensory nere supply is deried rom+ orsal nere o penis+ Ilioinguinal nere

Autono"ic Autonomic neres are deried rom Pe"8i! p"e4us8ia prostati! p"e4us

+ Sympathetic neres are asodilator+ %arasympathetic neres (S5,S,SG) are asodilator.

Autonomic fbers are distributed through pudendal nere.Muscles of %enis supplied by perineal branch o pudendalnerve.

Scrotum -he neres o scrotum include 4ranches o lumbar ple"us to anterolateral surace. 4ranches o sacral ple"us to posterior & inerior suraces.

+ Anterolateral surface 9enital branch o genitoemoralnere (B & 5).

+ Anterior surface: Anterior scrotal neres (branches oilioinguinal nere B)

+ %osterior surface: %osterior scrotal neres (branches operineal branch o pudendal nere S5,S,SG)

+ %osteroinferior surface %erineal branches o posteriorcutaneous nere o thigh S5,S.

Dartos "uscle 9enital branch o genitoemoral nere.

-estis -he autonomic neres o testis arise as testicular ple!us ofnerves & contain

+ >agal parasympathetic & isceral a'erent fbers.+ Sympathetic fbers rom (* segment o spinal cord.

!pididymis -esticular ple"us o neres!sophagus !sophagus is innerated by the esophageal ple!us ormed by+ >agal trun*s+ -horacic sympathetic trun*s ia greater splanchnic neres

& peri/arterial ple"us around let gastric & inerior phrenicarteries.

Stomach #y"pathetic nerve supply #rom -@/-H segments o spinalcord passes to celiac ple"us through greater splanchnic nere &is distributed through the ple"us around gastric & gastro/


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omental arteries.%arasy"pathetic nerve supply #rom

+ Anterior vagal trun" (deried mainly rom let agusnere)9ies o' epatic, duodenal & anterior gastric branches.

+ Posterior vagal trun" ( deried mainly rom right agus

nere)9ies o' a celiac branch , posterior gastric branches &branches to anterior & posterior suraces o stomach.

uodenum #y"pathetic nerve supply: (/ 2 (,6 segments o spinalcord.%arasy"pathetic nerve supply eried rom agus &greater and lesser splanchnic neres by the way o celiac &superior mesenteric ple"uses & reach the duodenum along itsarteries.

2e$unum &Ileum

(Reerence rom 4 3haurasia)Jere supply is deried rom sympathetic & parasympatheticneres

+ #y"pathetic -H/-BB

+ %arasy"pathetic rom agus nere (Reerence rom :eith..?oore)

+ (he sy"pathetic $bers originate in the -8/-B6segments o spinal cord & reach the superior mesentericnere ple"us through sympathetic trun*s & thoracicabdominopelic (greater,lesser & least) splanchnic neres.

+ (he parasy"pathetic $bers deried rom posterioragal trun*s.

3ecum #y"pathetic originate in lower thoracic part o spinal cord.Paras2pat'eti! derie rom agus nere. 4ranches rom sympathetic & parasympathetic neres ormthe superior "esenteric ple!us

Appendi" Same as cecumAscendingcolon

Sympathetic & parasympathetic (agus) neres rom superiormesenteric ple"us.

-ransersecolon

Superior mesenteric nere ple"us ia peri/arterial ple"uses oright & let colic arteries. -hese neres transmit sympathetic, parasympathetic (agal) &isceral a'erent nere fbers.

escending &sigmoidcolon

#y"pathetic: #rom lumbar part o sympathetic trun* ia + umbar splanchnic neres+ Superior mesenteric ple"us+ %eri/arterial ple"us

%arasy"pathetic: #rom pelic splanchnic neres ia

+ Inerior hypogastric ple"us & neres.%ancreas #y"pathetic Splanchnic neres through the ple"us.%arasy"pathetic >agus

ier Jeres o lier deried rom 7epatic ple!us ( deriatie oceliac ple"us)Which consists o

+ Sympathetic fbers rom celiac ple"us+ Parasympathetic fbers rom anterior & posterior agal


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trun*s.9allbladder &3ysticduct

Jeres to gall bladder & custic duct rom+ 3eliac ple"us < sympathetic & isceral a'erent fbers.+ >agus nere < parasympathetic fbers+ Right phrenic nere < Somatic a'erent fbers.

:idneys Rena" ner8e p"e4us which consists o

+ Sympathetic (,6+L, & parasympathetic fbers.;reters + Renal ple"us+ Abdominal aortic ple"us+ Superior hypogastric ple"us

Suprarenalglands

+ 3eliac ple"us+ Abdominopelic (greater, lesser & least splanchnic

neres)iaphragm

Motor nerve supply %hrenic neres (entral rami 3,3G,30)#ensory nerve supply:

+ Central part %hrenic nere+ Peripheral part lower @ thoracic neres

?uscles o posteriorabdominalwall

%soas ma$or Anterior rami o lumbar neres B, 5, .Iliacus #emoral nere (5/G)Kuadratus lumborum Anterior branches o -B5 & B/G neres.

;rinarybladder

;rinary bladder is supplied by 8esi!a" p"e4us o0 ner8es whichis made up o neres deried rom inerior hypogastric ple"us.#esical ple$us contains both sympathetic & parasympatheticcomponents% each o which contains motor(e'erent) &sensory(a'erent) fbers.

+ %arasympathetic e'erent fbers S,S,SG+ Sympathetic e'erent fbers -BB/5.+ Somatic pudendal nere (S5,S,SG)+ Sensory neres L#or detail see pageM18 4

3haurasiaN

?aleurethra Jeres are deried rom prostatic ple!us ( one o the pelicple"us)Parasympathetic nerves are rom 0nd to 8th sacral segments.

#emaleurethra

&esical ple!us 2 pudendal nerveE4p"anation$

+ %arasympathetic preganglionic fbers rom )n; to -t' sa!ra" segments o spinal cord. Synapse in esical enousple"us. %ost/ganglionic fbers reach smooth muscles.

+ Somatic fbers rom S5/SG. o not synapse in esicalenous ple"us.

+ Sensory fbers in pelic splanchnic neres reach to 5nd to

Gth sacral segments o spinal cord.+ %ostganglionic sympathetic fbers arise rom ple"us

around agina arteries.

Rectum Jere supply to rectum is deried rom sympathetic &parasympathetic systems.

+ #y"pathetic: rom lumbar spinal cord (B/5) coneyed


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iaumbar splanchnic nereypogastric=pelic ple"us%eri/arterial ple"us (o inerior mesenteric & superiorrectal arteries)

+ %arasy"patheti c rom S5/SG passing ia

%elic splanchnic nereset & right inerior hypogastric ple"us to the rectal(pelic) ple"us.

Anal canal Above pectinate line:+ Sympathetic Inerior hypogastric ple"us+ %arasympathetic %elic splanchnic nere S5,S.

Below pectinate line:+ Somatic inerior rectal nere (S5,S,SG) branch o

pudendal nere3!ternal anal sphincter:

+ Inerior rectal nere+ %erineal branch o Gth sacral nere

Caries &

uterinetubes

+ Ovarian ple!us eried rom renal, aortic &

hypogastric ple"us. 3ontains both sympathetic &parasympathetic nere fbers.

+ S2pat'eti!$ -B6/-BB are a'erent or pain as well ase'erent or asomotor.

+ %arasy"pathetic S5,S,SG are asodilator.+ Uterine ple!us

;terus Sympathetic & parasympathetic neres through Ineriorhypogastric & oarian ple"us.

+ #y"pathetic nerves are rom -B5 & B.+ %arasy"pathetic nerves are S5,S,SG.

>agina Lower ,9rd Supplied by pudendal nere through ineriorrectal & posterior labial branches o perineal nere.

Upper 09

rd

Supplied by+ #y"pathetic < B,5+ %arasy"pathetic < S5,S,SG.

Jeres are deried rom inerior hypogastric & uterovaginal ple$us.

%rostate9land

%rostate is supplied by %rostatic ple!us of nerves which isderies rom lower part o inerior hypogastric ple$us.


LYMP:ATIC DRAINA7E OF ABDOMEN& PELVIS

Anterolateralabdominalwall

ymphatic drainage o anterolateral abdominal wall ollows theollowing pattern. #uper$cial Ly"phatic vessels:

+ Superior to transumbilical plane rains into a$illarylymph nodes, howeer a ew drain into parasternal lymphnodes

• Inerior to transumbilical plane rain into superfcialinguinal lymph nodes.

Deep Ly"phatic vessels:


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+ rain into < e"ternal iliac 3ommon iliac Right & let lumbar (caal & aortic) lymphnodes.

%enis + eep Inguinal lymph nodes < glans penis+ Superfcial inguinal lymph nodes < rest o penis

-estis &!pididymus + Right & let lumbar (caal=aortic) lymph nodes+ %reaortic lymph nodesScrotum + Superfcial inguinal lymph nodes!sophagus !et gastric lymph nodes ( !'erent lymphatic essels rom

these nodes drain mainly to celiac lymph nodes)Stomach Stomach can be diided into G lymphatic territories

+ ;pper part o let B=rd < pancreaticosplenic nodes+ Right 5=rd < let gastric nodes+ ower part o let B=rd < Right gastroepiploic nodes+ %yloric part < pyloric lymph nodes

uodenum + Anterior lymphatic vessels rain upward intopancreaticoduodenal lymph nodes & into pyloric lymphnodes

+ Posterior lymphatic vessels rain downward iapancreaticoduodenal nodes to the superior mesentericlymph nodes

'erent lymphatic vessels o all above lymph nodes drain intoceliac lymph nodes.

2e$unum &Ileum

ymph passes through groups o lymph nodes+ 2u"ta/intestinal lymph nodes+ ?esenteric lymph nodes+ Superior central lymph nodes

'erent lymphatic vessels rom the mesenteric lymph nodesdrain into superior mesenteric lymph nodes.

3ecum ymph passes rom seeral mesenteric lymph nodes to ileocolic

lymph nodes , then to superior mesenteric lymph nodes.Appendi" Same as cecum in addition to appendicular nodesAscendingcolon

ymph passes rom !picolic & paracolicIleocolic & intermediate right colicnodessuperior mesenteric lymph nodes.

-ransersecolon

?iddle colic lymph nodesSuperior mesenteric lymph nodes

escending& sigmoidcolon

+ Intermediate colic lymph nodes+ Inerior mesenteric lymph nodes

!ymph rom let colic (e$ure may also drain to superiormesenteric lymph nodes.

Spleen %ancreaticosplenic lymph nodesceliac lymph nodes%ancreas + %ancreaticosplenic lymph nodes

+ 3eliac lymph nodes+ Superior mesenteric lymph nodes

ier + Superfcial lymphatics < caal , hepatic, paracardial &celiac lymph nodes.

+ )eep lymphatics < inerior ena caa & hepatic lymphnodes.

4ile duct + 3ystic nodes celiac lymph nodes+ ymph node o omental oramen celiac lymph nodes+ epatic lymph nodes celiac lymph nodes


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9allbladder &cystic duct

+ epatic lymph nodes celiac lymph nodes+ 3ystic lymph nodes celiac lymph nodes

:idneys Right & let lumbar ( caal & aortic ) lymph nodes;reters + Superior part < umbar lymph nodes

+ ?iddle part < common iliac lymph nodes

+ Inerior part < common, e"ternal or internal iliac lymphnodes.Suprarenalglands

ateral aortic ( lumbar) lymph nodes

;rinarybladder

+ !"ternal iliac nodes+ Internal iliac=lateral aortic nodes

?aleurethra

+ %rostatic urethra < internal iliac lymph nodes+ ?embranous urethra < internal iliac lymph nodes+ Anterior urethra < deep inguinal lymph nodes.

#emaleurethra

+ Internal iliac lymph nodes+ !"ternal iliac lymph nodes

Rectum + Upper half of rectu" Inerior mesenteric nodes aterpassing through pararectal & sigmoid nodes

+ Lower half of rectu" Internal iliac nodesAnal canal + Above pectinate line Internal iliac lymph nodes

common iliac & lumbar lymph nodes+ Below pectinate line Superfcial inguinal lymph nodes.

Caries &uterinetubes

ateral aortic & preaortic lymph nodes.

;terus lymphatic territories+ Upper ly"phatics rain into aortic & superfcial

inguinal lymph nodes.+ Mi;;"e "2p'ati!s rain into e"ternal iliac lymph

nodes.

+ Lower ly"phatics: !"ternal iliac, internal iliac & sacralnodes.>agina Upper ,9rd !"ternal iliac nodes

Middle ,9rd Internal iliac nodesLower ,9rd ?edial group o superfcial inguinal lymph nodes.

%rostategland

+ Internal iliac lymph nodes.+ !"ternal iliac lymph nodes.+ Sacral lymph nodes.


Abdomen & Pelvis Gross.medcom

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