1) ANATOMY (eFRCS) Flashcards by Syed Shah

A 44 year old man is stabbed in the back and the left kidney is injured. A haematoma forms, which of the following fascial structures will contain the haematoma?

A) Sibsons fascia
B) Denonvilliers fascia
C) Bucks fascia
D) Waldeyers fascia
E) Gerotas fascia

E) Gerotas Fascia

Each kidney and suprarenal gland is enclosed within a common and layer of investing fascia that is derived from the transversalis fascia into anterior and posterior layers (Gerotas fascia).

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A 73 year old man presents with a tumour at the central aspect of the posterior third of the tongue. To which of the following lymph node groups is it most likely to metastasise?

A) Submental
B) Submandibular
C) Bilateral deep cervical nodes
D) Contralateral deep cervical nodes
E) Ipsilateral deep cervical nodes

C) Bilateral Deep Cervical Nodes

Tumours of the posterior third of the tongue will typically metastasise early and bilateral nodal involvement is well recognised, this is most often true of centrally located tumours and those adjacent to the midline as the lymph vessels may cross the median plane at this location.

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From which structure is the central tendon of the diaphragm derived?

A) Septum transversum
B) Pleuroperitoneal folds
C) Diaphragmatic crura
D) Dorsal mesocardium
E) Oropharyngeal membrane

A) Septum transversum

The septum transversum is a thick ridge of mesodermal tissue in the developing embryo that separates the thoracic and abdominal cavities and forms the central tendon of the diaphragm.

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Which of the following vessels provides the greatest contribution to the arterial supply of the breast?

A) External mammary artery
B) Thoracoacromial artery
C) Internal mammary artery
D) Lateral thoracic artery
E) Subclavian artery

C) Internal mammary artery

60% of the arterial supply to the breast is derived from the internal mammary artery. The external mammary and lateral thoracic arteries also make a significant (but lesser) contribution. This is of importance clinically in performing reduction mammoplasty procedures.

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Which of the vessels listed below is the first branch of the external carotid artery?

A) Inferior thyroid artery
B) Superior thyroid artery
C) Ascending pharyngeal artery
D) Lingual artery
E) Occipital artery

B) Superior thyroid artery

The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived from the thyrocervical trunk.

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Which structure forms the superolateral boundary of the popliteal fossa?

A) Semimembranosus
B) Semitendinosus
C) Tendon of biceps femoris
D) Adductor magnus
E) None of the above

C) Tendon of biceps femoris

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Which of the following liver segments has a dual blood supply from both right and left hepatic arteries?

A) I
B) II
C) IV
D) V
E) VIII

A) I

The caudate lobe has dual arterial and venous supply.

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A 43 year old lady is undergoing a total thyroidectomy for an extremely large goitre. The surgeons decide that access may be improved by division of the infra hyoid strap muscles. At which of the following sites should they be divided?

A) In their upper half
B) In their lower half
C) In the middle
D) At their origin from the hyoid
E) At the point of their insertion

A) In their upper half

Should the strap muscles require division during surgery they should be divided in their upper half. This is because their nerve supply from the ansa cervicalis enters in their lower half.

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At which level does the inferior vena cava pass through the diaphragm?

A) T4
B) T10
C) T12
D) T8
E) T6

D) T8

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The ano rectal ring is formed by all of the following, except:

A) External anal sphincter
B) Internal anal sphincter
C) Puborectalis
D) Pubococcygeus
E) Transversus perineii

E) Transversus perineii

The muscles of the anorectal ring include; puborectalis, superior aspects of the internal and external sphincters.

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A 73 year old lady presents with symptoms of faecal incontinence. On examination she has weak anal sphincter muscles. What are the main nerve root values of the nerves supplying the external anal sphincter?

A) S 2, 3
B) L5, S1
C) S 4, 5
D) S5
E) S 2, 3, 4

E) S 2, 3, 4

The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve, this has root values of S2, 3 and the perineal branch of S4.

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Which structure forms the lateral border of the femoral triangle?

A) Adductor longus
B) Femoral vein
C) Sartorius
D) Adductor magnus
E) Rectus femoris

C) Sartorius

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A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the lower uterine body. To which nodal region will the tumour initially metastasise?

A) Para aortic nodes
B) Inguinal nodes
C) Pre sacral nodes
D) Mesorectal lymph nodes
E) Iliac lymph nodes

E) Iliac lymph nodes

Tumours of the cervix/ lower uterine body will tend to spread to the iliac nodes initially. Lesions of the upper part of the uterus will spread to the lumbar lymph nodes of the para-aortic chain. When the tumour is expanding to cross different nodal margins this is of considerable clinical significance if nodal clearance is performed during a Wertheims type hysterectomy.

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Which of the following is a content of the adductor canal?

A) Saphenous vein
B) Profunda branch of the femoral artery
C) Saphenous nerve
D) Femoral nerve
E) Sural nerve

C) Saphenous nerve

It contains the saphenous nerve and the superficial branch of the femoral artery.

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Which of the following fascial structures encases the apex of the lungs?

A) Waldeyers fascia
B) Sibsons fascia
C) Pretracheal fascia
D) Clavipectoral fascia
E) None of the above

B) The suprapleural fascia (Sibson’s fascia) runs from C7 to the first rib and overlies the apex of both lungs.

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A 25 year old lady with autoimmune haemolytic anaemia is due to undergo a splenectomy. Which of the options listed below would represent the most likely location for an accessory spleen?

A) Pancreatic tail
B) Small bowel mesentery
C) Greater omentum
D) Spleno-colic ligament
E) Splenic hilum

E) Splenic hilum

Accessory spleen is a common anomaly and compromise the outcome of splenectomy performed for haemolytic anaemia. They occur in up to 20% of patients. 80% of accessory spleens are located at the hilum.

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How many major hepatic veins enter the inferior vena cava directly?

A) 1
B) 5
C) 3
D) 2
E) 4

D) 2

The middle and left hepatic veins usually fuse prior to entering the IVC.The caudate lobe has its own drainage and is not drained by the main hepatic veins.

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An 80 year old lady with a caecal carcinoma is undergoing a right hemicolectomy performed through a transverse incision. The procedure is difficult and the incision is extended medially by dividing the rectus sheath. Brisk arterial haemorrhage ensues. From which of the following does the damaged vessel originate?

A) Common iliac artery
B) Internal iliac artery
C) Femoral artery
D) Superior vesical artery
E) External iliac artery

E) External iliac artery

The vessel damaged is the epigastric artery. This originates from the external iliac artery.

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Which of the following is not contained within the middle mediastinum?

A) Pericardium
B) Main bronchi
C) Arch of the azygos vein
D) Thoracic duct
E) Aortic root

D) Thoracic duct
The thoracic duct lies within the posterior and superior mediastinum.

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Which of the following hepatic structures is not directly related to fibrous connective tissue?

A) Left hepatic duct
B) Right portal pedicle
C) Left lateral sectional bile duct
D) Transverse portion of the left portal vein
E) Gallbladder

A) Left hepatic duct

The left hepatic duct is extrahepatic and this makes it an attractive site for surgical reconstruction. The other structures are all intimately related to the fibrous plates and sheaths that support the liver parenchyma.

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Which of the following is the most prevalent hepatic arterial anomaly?

A) Common hepatic artery from the superior mesenteric artery
B) Accessory right hepatic artery from superior mesenteric artery
C) Left gastric artery from left hepatic artery
D) Left hepatic artery from left gastric artery
E) Replaced right hepatic artery from the left gastric artery

D) Left hepatic artery from left gastric artery

Common hepatic arterial anomalies:
RHA from SMA
LHA from LGA

The aberrant origin of the LHA is a risk factor in radical gastrectomy. The commonest hepatic arterial anomaly is a replaced RHA from the SMA. Note that in this question we have the option of accessory rather than replaced making the option D the correct answer.

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The foramen marking the termination of the adductor canal is located in which of the following?

A) Adductor magnus
B) Sartorius
C) Semimembranosus
D) Adductor longus
E) Adductor brevis

A) Adductor magnus

The foramen marking the distal limit of the adductor canal is contained within adductor magnus. The vessel passes through this region to enter the popliteal fossa.

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With regards to the internal jugular vein, which of the following statements is untrue?

A) It lies within the carotid sheath
B) The hypoglossal nerve is closely related to it as it passes near the atlas
C) It is the continuation of the sigmoid sinus
D) The vagus nerve is closely related to it within the carotid sheath
E) The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein

E) The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein

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A 34 year old lady suffers from hyperparathyroidism. The right inferior parathyroid is identified as having an adenoma and is scheduled for resection. From which of the following embryological structures is it derived?

A) Second pharyngeal pouch
B) Third pharyngeal pouch
C) Fourth pharyngeal pouch
D) First pharyngeal pouch
E) None of the above

B) Third pharyngeal pouch

The inferior parathyroid is a derivative of the third pharyngeal pouch. The superior parathyroid originates from the fourth pharyngeal pouch.

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An 18 year old lady with troublesome hyperhidrosis of the hands and arms is due to undergo a sympathectomy to treat the condition. Which of the following should the surgeons divide to most effectively treat her condition? A) Sympathetic ganglia at T1 and T2 B) Superior cervical ganglion C) Sympathetic ganglia at T2 and T3 D) Stellate ganglion E) Sympathetic ganglia at T1, T2 and T3

C) Sympathetic ganglia at T2 and T3 To treat hyperhidrosis the sympathetic ganglia at T2 and T3 should be divided. Dividing the other structures listed would either carry a risk of Horners syndrome or be ineffective.

Which of the following lies at the anterior aspect of the ischiorectal fossa? A) Urogenital diaphragm B) Obturator internus C) Alcocks canal D) Levator ani E) Inferior rectal nerve

A) Urogenital diaphragm

A child presents with an ectopic testis. Which of the embryological structures listed below may contribute to this condition? A) Uranchus B) Gubernaculum C) Vitellointestinal duct D) Paramesonephric duct E) Wolffian duct

B) Gubernaclum The gubernaculum is the structure that guides testicular descent and may thus be responsible for an ectopic testis.

Which of the following scans is most likely to be helpful in identifying oxyphil cells? A) MIBG scan B) VQ scan C) Sestamibi scan D) Radioactive iodine uptake scan E) Somatostatin receptor scintigraphy

C) Sestamibi scan Oxyphil cells are found in the parathyroid glands and are therefore most likely to be found using a sestamibi scan

A 23 year old man is stabbed in the neck, in the region between the omohyoid and digastric muscles, the injury is explored surgically. At operation a nerve injury is identified immediately superior to the lingual artery as it branches off the external carotid artery. Which of the following is the most likely result of this injury? A) Paralysis of the ipsilateral side of the tongue B) Abduction of the ipsilateral vocal cord C) Winging of the scapula D) Paralysis of the ipsilateral hemi diaphragm E) Inability to abduct the shoulder

A) A) Paralysis of the ipsilateral side of the tongue The hypoglossal nerve runs anterior to the external carotid, above the lingual arterial branch. If damaged then ipsilateral paralysis of the genioglossus, hyoglossus and styloglossus muscles will occur. If the patient is asked to protrude their tongue then it will tend to point to the affected side.

Which of the following is not a content of the anterior triangle of the neck? A) Vagus nerve B) Submandibular gland C) Phrenic nerve D) Internal jugular vein E) Hypoglossal nerve

C) Phrenic nerve

During a thyroidectomy the operating surgeon mobilises the inferior thyroid artery. From which of the following vessels is this structure derived? A) Subclavian artery B) Internal carotid artery C) External carotid artery D) Thyrocervical trunk E) Thyroid ima artery

D) Thyrocervical trunk

During a laparoscopic cholecystectomy the cystic artery is transected. From which vessel does this structure usually originate? 1) Left gastric artery 2) Common hepatic artery 3) Right hepatic artery 4) Superior mesenteric artery 5) Gastroduodenal artery

3) Right hepatic artery The cystic artery lies in the centre of Calots triangle and originates from the right hepatic artery in most cases.

What is the course of the median nerve relative to the brachial artery in the upper arm? A) Medial to anterior to lateral B) Lateral to posterior to medial C) Medial to posterior to lateral D) Medial to anterior to medial E) Lateral to anterior to medial

E) Lateral to anterior to medial The median nerve descends lateral to the brachial artery, it usually passes anterior to the artery to lie on its medial side. It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow. It enters the forearm between the two heads of the pronator teres muscle.

Which of the following is not a content of the posterior triangle of the neck? A) Spinal accessory nerve B) Phrenic nerve C) External jugular vein D) Occipital lymph nodes E) Internal jugular vein

E) Internal jugular vein

How many vessels typically provide arterial supply to the adrenal gland? A) 1 B) 2 C) 3 D) 4 E) 5

C) 3 The adrenals are typically supplied by 3 arterial vessels, the superior is a branch of the inferior cardiophrenic artery, the middle from the aorta and the inferior from the renal artery.

A 21 year old man has an inguinal hernia and is undergoing a surgical repair. As the surgeons approach the inguinal canal they expose the superficial inguinal ring. Which of the following forms the lateral edge of this structure? A) Conjoint tendon B) Inferior epigastric artery C) Rectus abdominis muscle D) External oblique aponeurosis E) Transversalis fascia

D) External oblique aponeurosis The external oblique aponeurosis forms the anterior wall of the inguinal canal and also the lateral edge of the superficial inguinal ring. The rectus abdominis lies posteromedially and the transversalis posterior to this.

A 45 year old lady is undergoing a Whipples procedure for carcinoma of the pancreatic head. The bile duct is transected. Which of the following vessels is mainly responsible for the blood supply to the common bile duct? A) Left hepatic artery B) Right hepatic artery C) Portal vein D) Left gastric artery E) None of the above

B) Right hepatic artery Blood supply to bile duct 60% from gastroduodenal artery 40% from the hepatic artery

What is the level of the aortic bifurcation? A) L2 B) L3 C) L1 D) L5 E) L4

E) L4

How many unpaired branches leave the abdominal aorta to supply the abdominal viscera? A) One B) Two C) Three D) Four E) Five

C) Three

A 63 year old lady presents with pain on the medial aspect of her thigh. Investigations show a large pelvic tumour. Compression of which of the nerves listed below is the most likely underlying cause? A) Sciatic B) Genitofemoral C) Obturator D) Ilioinguinal E) Femoral cutaneous

C) Obturator The obturator nerve is a recognised contributor to innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally.

A motorcyclist is injured in a road traffic accident and is not wearing a helmet. He suffers a severe closed head injury and develops raised intracranial pressure. The first cranial nerve to be affected by this process is likely to be: A) Oculomotor B) Hypoglossal C) Motor branch of the trigeminal D) Abducens E) Trochlear

D) Abducens The abducens nerve (CN VI) has the longest intra cranial course and is thus the most susceptible to raised intra cranial pressure. It also passes over the petrous temporal bone and 6th nerve palsies are also seen in mastoiditis.

A 67 year old man undergoes a carotid endarterectomy and seems to recover well following surgery. When he is reviewed on the ward post operatively he complains that his voice is hoarse. What is the most likely cause? A) Damage to the hypoglossal nerve B) Damage to the accessory nerve C) Damage to the glossopharyngeal nerve D) Damage to the cervical plexus E) Damage to the vagus

E) Damage to the vagus Many of these nerves are at risk of injury during carotid surgery. However, only damage to the vagus would account for difficulties in speech.

A 48 year old motor cyclist sustains a complex lower limb fracture in a motor accident. For a time the popliteal artery is occluded and eventually repaired. Subsequently he develops a compartment syndrome and the anterior and superficial posterior compartments of the lower leg are decompressed. Unfortunately, the operating surgeon neglects to decompress the deep posterior compartment. Which of the following muscles is least likely to be affected as a result? A) Flexor digitorum longus B) Plantaris C) Tibialis posterior D) Flexor hallucis longus E) None of the above

B) Plantaris The plantaris muscle lies within the superficial posterior compartment of the lower leg and will not therefore be affected as a result of this error.

An 18 year old man is stabbed in the axilla during a fight. His axillary artery is lacerated and repaired. However, the surgeon neglects to repair an associated injury to the upper trunk of the brachial plexus. Which of the following muscles is least likely to demonstrate impaired function as a result? A) Palmar interossei B) Infraspinatus C) Brachialis D) Supinator brevis E) None of the above

A) Palmar interossei The palmar interossei are supplied by the ulnar nerve. Which lies inferiorly and is therefore less likely to be injured.

Through which of the following foramina does the genital branch of the genitofemoral nerve leave the abdominal cavity? A) Superficial inguinal ring B) Sciatic notch C) Obturator foramen D) Femoral canal E) Deep inguinal ring

E) Deep inguinal ring The genitofemoral nerve divides into two branches as it approaches the inguinal ligament. The genital branch passes anterior to the external iliac artery through the deep inguinal ring into the inguinal canal. It communicates with the ilioinguinal nerve in the inguinal canal (though this is seldom of clinical significance).

At which level is the hilum of the left kidney located? A) L1 B) L2 C) T12 D) T11 E) L3

A) L1 This is also the transpyloric plane

How many bronchopulmonary segments does the right lung have? A) 5 B) 15 C) 10 D) 12 E) 13

C) 10 There are 10 bronchopulmonary segments in the right lung. Each is supplied by a segmental bronchus, artery and vein. There is no communication between segments.

Which of the structures listed below is not a content of the carotid sheath? A) Internal jugular vein B) Internal carotid artery C) Vagus nerve D) Recurrent laryngeal nerve E) Common carotid artery

D) Recurrent laryngeal nerve

A 56 year old lady is undergoing an adrenalectomy for Conns syndrome. During the operation the surgeon damages the middle adrenal artery and haemorrhage ensues. From which of the following structures does this vessel originate? A) Aorta B) Renal artery C) Splenic artery D) Coeliac axis E) Superior mesenteric artery

A) Aorta The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery typically arises from the renal vessels.

A 23 year old lady with troublesome axillary hyperhidrosis is undergoing a thorascopic sympathectomy to treat the condition. Which of the following structures will need to be divided to access the sympathetic trunk? A) Intercostal vein B) Intercostal artery C) Parietal pleura D) Visceral pleura E) None of the above

C) Parietal pleura

A 35 year old man presents to the surgical clinic with a suspected direct inguinal hernia. These will pass through Hesselbach's triangle. Which of the following forms the medial edge of this structure? A) External oblique aponeurosis B) Inferior epigastric artery C) Inferior epigastric vein D) Rectus abdominis E) Iliohypogastric nerve

D) Rectus abdominis

During the course of a laparotomy a surgeon palpates the hepatoduodenal ligament. A pulsation is noted, dorsally and to the right of the CBD. What is this most likely to represent ? A) A normally sited gastroduodenal artery B) A normally sited right renal artery C) A normally sited common hepatic artery D) A normally sited right hepatic artery E) A replaced right hepatic artery

E) A replaced right hepatic artery Replaced right hepatic artery is one of the commonest variants in hepatic arterial anatomy. In this situation it typically arises from the SMA. In this situation it courses dorsal to the pancreatic head and portal vein and identified dorsolaterally to the CBD. A replaced left hepatic artery may arise from the left gastric artery and lie within the gastrohepatic ligament.

A 65 year old man with long standing atrial fibrillation develops an embolus to the lower leg. The decision is made to perform an embolectomy, utilising a trans popliteal approach. After incising the deep fascia, which of the following structures will the surgeons encounter first on exploring the central region of the popliteal fossa? A) Popliteal vein B) Common peroneal nerve C) Popliteal artery D) Tibial nerve E) None of the above

D) Tibial nerve The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa.

Which of the following liver segments routinely drain into the right hepatic vein? A) I B) II C) III D) IV E) V

E) V Segment V is located in the right hemiliver and will usually drain via the right hepatic vein. Segment I (Caudate lobe) will tend to drain directly into the IVC.

In a traditional Patey mastectomy which of the following muscles is routinely divided? A) Pectoralis major B) Pectoralis minor C) Latissimus dorsi D) Serratus anterior E) None of the above

B) Pectoralis minor Patey devised his modification of the radical mastectomy which preserved the pectoralis major and allowed the division of pectoralis minor. Stronger assistants (and sentinel node biopsy) have made this less common now.

An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following forms the posterior wall of the femoral ring? 1) Pectineal ligament 2) Lacunar ligament 3) Inguinal ligament 4) Adductor longus 5) Sartorius

1) Pectineal ligament

A 34 year old lady presents with symptoms of faecal incontinence. Ten years previously she gave birth to a child by normal vaginal delivery. Injury to which of the following nerves is most likely to account for this process? A) Genitofemoral B) Ilioinguinal C) Pudendal D) Hypogastric autonomic plexus E) Obturator

C) Pudendal Damage to the pudendal nerve is classically associated with faecal incontinence and it is for this reason that sacral neuromodulation is a popular treatment for the condition. Injury to the hypogastric autonomic nerves is an aetiological factor in the development of constipation.

A 48 year old lady is undergoing an axillary node clearance for breast cancer. Which of the structures listed below are most likely to be encountered during the axillary dissection? A) Thoracodorsal trunk B) Cords of the brachial plexus C) Internal mammary artery D) Thoracoacromial artery E) None of the above

A) Thoracodorsal trunk The thoracodorsal trunk runs through the nodes in the axilla. If injured it may compromise the function and blood supply to latissimus dorsi, which is significant if it is to be used as a flap for a reconstructive procedure.

A 53 year old lady is recovering following a difficult mastectomy and axillary nodal clearance for carcinoma of the breast. She complains of shoulder pain and on examination has obvious winging of the scapula. Loss of innervation to which of the following is the most likely underlying cause? A) Latissimus dorsi B) Pectoralis minor C) Pectoralis major D) Serratus anterior E) Rhomboids

D) Serratus anterior Winging of the scapula is most commonly the result of long thoracic nerve injury or dysfunction. Iatrogenic damage during the course of the difficult axillary dissection is the most likely cause in this scenario. Damage to the rhomboids may produce winging of the scapula but would be rare in the scenario given.

Which of the following structures lies on the medial aspect of Calots triangle? A) Common hepatic duct B) Liver C) Cystic artery D) Right hepatic artery E) Portal vein

A) Common hepatic duct

The following structures are closely related to the brachiocephalic artery except: A) Trachea posteriorly B) Right brachiocephalic vein C) Inferior thyroid vein D) Right recurrent laryngeal nerve E) None of the above

D) Right recurrent laryngeal nerve There is no brachiocephalic artery on the left, however the left brachiocephalic vein lies anteriorly to the roots of all the 3 great arteries (including the brachiocephalic artery). The right recurrent laryngeal nerve has no relation to the brachiocephalic artery.

Which of the following nerves innervates the long head of the biceps femoris muscle? A) Inferior gluteal nerve B) Obturator nerve C) Common peroneal nerve D) Superior gluteal nerve E) Tibial nerve

E) Tibial nerve

During a neck exploration for suspected hyperparathyroidism the surgeon encounters difficulty in identifying the inferior parathyroid gland. The initial dissection focused on the posterior aspect of the thyroid lobe to the inferior thyroid artery. Where should the operating surgeon search next? A) Mediastinum B) Lower pole of the thymus C) Lateral to the inferior cornu of the thyroid cartiledge D) Along the thyrothymic ligament E) In the groove between the middle thyroid vein and the recurrent laryngeal nerve

D) Along the thyrothymic ligament Up to 25% of inferior parathyroid glands will be located along the thyrothymic ligament.

Theme: Nerve supply of muscles encountered in breast surgery A. Suprascapular nerve B. Long thoracic nerve C. Thoracodorsal nerve D. Lateral pectoral nerve E. Medial pectoral nerve The muscles listed below are commonly encountered during breast surgery. Please match them to their predominant nerve supply. Each option may be used once, more than once or not at all. Latissimus dorsi Pectoralis minor Serratus anterior

Thoracodorsal nerve Medial pectoral nerve Long thoracic nerve

A 45 year old lady is due to undergo a breast reconstruction using the latissimus dorsi muscle. Which of the following provides it's blood supply? A) Internal mammary artery B) Thoracoacromial artery C) Thoracodorsal artery D) Suprascapular artery E) Subscapular artery

C) Thoracodorsal artery

What is the nerve root value of the external urethral sphincter? A) S4 B) S1, S2, S3 C) S2, S3, S4 D) L3, L4, L5 E) L5, S1, S2

B) S1, S2, S3 The external urethral sphincter is innervated by branches of the pudendal nerve, therefore the root values are S2, S3, S4.

The first root of the brachial plexus commonly arises at which of the following levels? A) C6 B) C5 C) C3 D) C8 E) C2

B) C5 It begins at C5 and has 5 roots. It ends with a total of 15 nerves of these 5 are the main nerves to the upper limb (axillary, radial, ulnar, musculocutaneous and median)

A 33 year old man is stabbed in the right chest and undergoes a thoracotomy. The right lung is mobilised and the pulmonary ligament inspected. Which of the following structures does not lie within the pulmonary ligament of the right lung? A) Pulmonary artery B) Azygos vein C) Pulmonary vein D) Bronchus E) None of the above

B) Azygos vein The pulmonary ligament is formed by a pleural condensation at the hilum of the lung. It encases the pulmonary vessels and trachea. The azygos vein is not contained within it.

During a thyroidectomy, a surgeon identified the superior laryngeal nerve. From which of the structures below is it derived? A) Glossopharyngeal nerve B) Superior ganglion of the vagus C) Accessory nerve D) Inferior ganglion of the vagus E) Hypoglossal nerve

D) Inferior ganglion of the vagus

What is the most common anatomical variant of the pancreas? A) Annular pancreas B) Pancreas divisum C) Ectopic rests of pancreatic tissue D) Congenital pseudocyst E) Absent pancreas

B) Pancreas divisum

A 53 year old man presents with an inguinal hernia. Which of the following surface landmarks may be used to identify the location of the deep inguinal ring? A) 4cm superior to the femoral vein B) 4cm inferomedially to the femoral artery C) Mid inguinal point D) Halfway between the anterior superior iliac spine and the symphysis pubis E) Mid point of the inguinal ligament

E) Mid point of the inguinal ligament The surface markings of the deep inguinal ring are a commonly examined topic and should be memorised. The surface marking is the midpoint of the inguinal ligament. The mid inguinal point is the surface marking for the femoral artery. The pubic tubercle marks the site

A 22 year old man is involved in a fight and sustains a stab wound in his upper forearm. On examination there is a small, but deep laceration. There is an obvious loss of pincer movement involving the thumb and index finger with minimal loss of sensation. The most likely nerve injury is to the: A) Ulnar nerve B) Radial nerve C) Anterior interosseous nerve D) Axillary nerve E) Median nerve

C) Anterior interosseous nerve

A 44 year old man has a malignant melanoma and is undergoing a block dissection of the groin. The femoral triangle is being explored for intra operative bleeding. Which of the following forms the medial border of the femoral triangle? A) Femoral artery B) Biceps femoris C) Adductor longus D) Sartorius E) Adductor magnus

C) Adductor longus

A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter? A) Bladder neck B) Prostatic urethra C) Bulbar urethra D) Membranous urethra E) Internal sphincter

D) Membranous urethra The membranous urethra is the least distensible portion of the urethra. This is due to the fact that it is surrounded by the external sphincter.

Which of the structures listed below is not usually located near Cantlie's line? A) Middle hepatic vein B) Gallbladder C) Inferior vena cava D) Caudate lobe E) Segment VI

E) Segment VI

A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter? 1) Bladder neck 2) Prostatic urethra 3) Bulbar urethra 4) Membranous urethra 5) Internal sphincter

4) Membranous urethra

A 40 year old lady presents with varicose veins, these are found to originate from the short saphenous vein. As the vein is mobilised close to its origin which structure is at greatest risk of injury? 1) Popliteal artery 2) Tibial nerve 3) Sural nerve 4) Common peroneal nerve 5) Sciatic nerve

3) Sural nerve The sural nerve is closely related and damage to this structure is a major cause of litigation. The other structures may all be injured but the risks are lower.

A 42 year old lady is reviewed in the outpatient clinic following a routine surgical procedure. She complains of diminished sensation at the lateral aspect of her foot. Which of the following nerves is likely to be affected? 1) Sural 2) Superficial peroneal 3) Deep peroneal 4) Medial plantar 5) Lateral plantar

1) Sural The sural nerve supplies the lateral aspect of the foot. It runs alongside the short saphenous vein and may be injured in short saphenous vein surgery.

A 43 year old lady is donating her left kidney to her sister and the surgeons are harvesting the left kidney. Which of the following structures will lie most anteriorly at the hilum of the left kidney? 1) Left renal artery 2) Left renal vein 3) Left ureter 4) Left ovarian vein 5) Left ovarian artery

2) Left renal vein The renal veins lie most anteriorly, then artery and ureter lies posteriorly.

A 45 year old man is undergoing a lymph node biopsy from the posterior triangle of his neck. Which structure forms the posterior border of this region? 1) Trapezius muscle 2) Digastric muscle 3) External jugular vein 4) Omohyoid muscle 5) Sternocleidomastoid muscle

1) Trapezius muscle

The transversalis fascia contributes to which of the following? 1) Deep inguinal ring 2) Cremaster muscle and fascia 3) Inguinal ligament 4) External spermatic fascia 5) Pectineal ligament

1) Deep inguinal ring The principal outpouching of the transversalis fascia is the internal spermatic fascia. The mouth of the outpouching is the deep inguinal ring.

Which of the following structures has the longest extra hepatic course? 1) Left hepatic duct 2) Right hepatic duct 3) Right anterior sectional bile duct 4) Right posterior sectional bile duct 5) Left lateral sectional bile duct

1) Left hepatic duct The left hepatic duct is extra hepatic and in some individuals has quite a long extra hepatic course.

A 53 year old man with a carcinoma of the lower third of the oesophagus is undergoing an oesophagogastrectomy. As the surgeons mobilise the lower part of the oesophagus, where are they most likely to encounter the thoracic duct? A) Anterior to the oesophagus B) On the left side of the oesophagus C) On the right side of the oesophagus D) Immediately anterior to the azygos vein E) Posterior to the oesophagus

E) Posterior to the oesophagus

A 56 year old man is undergoing a superficial parotidectomy for a pleomorphic adenoma. During the dissection of the parotid, which of the following structures will be encountered lying most superficially? A) Retromandibular vein B) Facial nerve C) External carotid artery D) Occipital artery E) Maxillary artery

B) Facial nerve The facial nerve is the most superficial structure in the parotid gland. Slightly deeper to this lies the retromandibular vein, with the arterial layer lying most deeply.

Theme: Branches of the abdominal aorta A. L1 B. T10 C. T12 D. L3 E. L4 F. S1 Please select the level at which the following aortic branches are most likely to be located. Each option may be used once, more than once or not at all. Inferior mesenteric artery Superior mesenteric artery Common iliac vessels

L3 L1 L4

Which of the following overlies the outer muscular layer of the intrathoracic oesophagus? A) Serosa B) Meissners plexus C) Auerbach's plexus D) Loose connective tissue E) None of the above

D) Loose connective tissue The oesophagus has no serosal covering and hence holds sutures poorly. The Auerbach's and Meissner's nerve plexuses lie in between the longitudinal and circular muscle layers and submucosally. The sub mucosal location of the Meissner's nerve plexus facilitates its sensory role.

A 45 year old lady is due to undergo an axillary node clearance as treatment for breast cancer. Division of which of the following is necessary to gain access to the level I axillary nodes? A) Pectoralis major B) Pectoralis minor C) Clavipectoral fascia D) Deltoid E) Sibsons fascia

C) Clavipectoral fascia In order to access the axillary contents it is necessary to formally divide the clavipectoral fascia. Once this has been achieved the level one contents can be accessed. Retraction of pectoralis major and minor allows access to the level II and III nodes.

A 45 year old lady is undergoing a Whipples procedure for carcinoma of the pancreatic head. The bile duct is transected. Which of the following vessels is mainly responsible for the blood supply to the bile duct? A) Cystic artery B) Hepatic artery C) Left gastric artery D) Portal vein E) None of the above

B) Hepatic artery The bile duct has an axial blood supply which is derived from the hepatic artery and from retroduodenal branches of the gastroduodenal artery.

A 74 year old man is assessed as having oesophageal varices at endoscopy. What is the venous drainage of these varices? A) Left gastric vein B) Splenic vein C) Portal vein D) Hemiazygos vein E) Renal vein

D) Hemiazygos vein Remember that with impairment of flow through the portal system. The feeding vessels will be the gastric veins and drainage superiorly to the azygos system (i.e. reverse flow).

The caudate lobe of the liver corresponds to which segment of Couinauds classification? A) Segment I B) Segment III C) Segment V D) Segment IV E) Segment II

A) Segment I

Where does Stensens duct primarily open? A) Floor of the mouth B) Opposite the second molar tooth C) Adjacent to the foramen caecum D) Opposite the fifth molar tooth E) Post nasal space

B) Opposite the second molar tooth Stensens duct conveys secretions from the parotid gland and these enter the oral cavity at the level of the second molar tooth.

Which of the following vessels is least likely to drain directly into the inferior vena cava? A) Left hepatic vein B) Right hepatic vein C) Right common iliac vein D) Inferior mesenteric vein E) Right testicular vein

D) Inferior mesenteric vein

During a thyroidectomy for Graves disease there are difficulties encountered in ligating the superior thyroid artery, a nerve lying adjacent to it is damaged. What is the most likely result of this? A) Impaired function of the cricothyroid muscle B) Impaired function of the posterior cricoarytenoid muscle C) Impaired function of the lateral cricoarytenoid muscle D) Impaired function of the thyroarytenoid muscle E) Impaired function of the oblique arytenoid muscle

A) Impaired function of the cricothyroid muscle Damage to the superior laryngeal nerve will impair the function of the cricothyroid muscle. As a result it may be difficult for people such as professional singers, to reach high pitched notes.

A male infant is born by emergency cesarean section at 39 weeks gestation for foetal distress. Soon after the birth the baby becomes progressively hypoxic and on examination is found to have a scaphoid abdomen. What is the most likely underlying diagnosis? A) Intestinal malrotation B) Hiatus hernia C) Foramen of Bochdalek hernia D) Foramen of Morgagni hernia E) Tracheo-oesphageal fistula

C) Foramen of Bochdalek hernia The finding of a scaphoid abdomen and respiratory distress suggests extensive intra thoracic herniation of the abdominal contents. This is seen most frequently with Bochdalek hernias. Morgagni hernias seldom present in such a dramatic fashion. The other options do not typically present with the symptoms and signs described.

A 78 year old man is due to undergo an endarterectomy of the internal carotid artery. Which of the following nervous structures are most at risk during the dissection? A) Lingual nerve B) Recurrent laryngeal nerve C) Hypoglossal nerve D) Phrenic nerve E) Sympathetic chain

C) Hypoglossal nerve During a carotid endarterectomy the sternocleidomastoid muscle is dissected, with ligation of the common facial vein and then the internal jugular is dissected exposing the common and the internal carotid arteries. The nerves at risk during the operation include: Hypoglossal nerve Greater auricular nerve Superior laryngeal nerve The sympathetic chain lies posteriorly and is less prone to injury in this procedure.

The veins draining the greater curvature of the stomach have the greatest drainage into which of the following? A) Superior mesenteric vein B) Portal vein C) Splenic vein D) Inferior mesenteric vein E) Inferior vena cava

C) Splenic vein

Which of the following hepatic structures is least likely to follow the pattern of biliary drainage? A) Right hepatic artery and its branches B) Left hepatic artery and its branches C) Right portal vein and its branches D) Left portal vein and its branches E) None of the above

D) Left portal vein and its branches The left portal vein had an embryonic function as a conduit between the umbilical vein and the ductus venosus and therefore does not have a distribution pattern that follows the biliary anatomy.

A 17 year old male has a suspected testicular torsion and the scrotum is to be explored surgically. The surgeon incises the skin and then the dartos muscle. What is the next tissue layer that will be encountered during the dissection? A) Visceral layer of the tunica vaginalis B) Cremasteric fascia C) Parietal layer of the tunica vaginalis D) External spermatic fascia E) Internal spermatic fascia

D) External spermatic fascia