6- Abdomen & Pelvic MSQs Only (1) Flashcards
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A patient undergoes a femoral hernia repair and at operation the surgeon decides to enter the abdominal cavity to resect small bowel. She makes a transverse incision two thirds of the way between umbilicus and the symphysis pubis. Which of the structures listed below is least likely to be divided?
Posterior lamina of the rectus sheath
An incision at this level lies below the arcuate line and the posterior wall of the rectus sheath is deficient at this level.
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What is the lymphatic drainage of the ovaries?
Para-aortic nodes
The lymphatic drainage of the ovary follows the gonadal vessels and drainage is therefore to the
para-aortic nodes.
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A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated; into which
structure does it drain?
Inferior vena cava
The testicular venous drainage begins in the septa and these veins together with those of the tunica vasculosa converge on the posterior border of the testis as the pampiniform plexus. The pampiniform plexus drains to the testicular vein. The left testicular vein drains into the left renal vein.
The right testicular vein drains into the inferior vena cava.
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A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation of the uterine artery. At which site does it insert into the bladder?
Base
The ureters enter the bladder at the upper lateral aspect of the base of the bladder. They are about 5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.
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A 6 month old child is brought to the surgical clinic because of non descended testes. What is the main structure that determines the descent path of the testicle?
Gubernaculum
The gubernaculum is a ridge of mesenchymal tissue that connects the testis to the inferior aspect of the scrotum. Early in embryonic development the gubernaculum is long and the testis are located on the posterior abdominal wall. During foetal growth the body grows relative to the gubernaculum, with resultant descent of the testis.
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What is the most important structure involved in supporting the uterus?
Central perineal tendon
The central perineal tendon provides the main structural support to the uterus. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when other structures are intact.
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What is the lymphatic drainage of the male spongy urethra?
Deep inguinal nodes
The lymphatic drainage of the spongy urethra and the glans penis is to the deep inguinal nodes. The
prostatic and membranous urethra drains to the internal iliac nodes.
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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?
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.
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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?
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.
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Which of the structures listed below accompanies the aorta as it traverses the aortic hiatus?
Thoracic duct
The aorta is accompanied by the thoracic duct as it traverses the aortic hiatus. The vagal trunks accompany the oesophagus which passes through the muscular part of the diaphragm on the right.
The right phrenic nerve accompanies the IVC as it passes through the caval opening. The left phrenic nerve passes through the muscular part of the diaphragm anterior to the central tendon on the left.
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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 remnant?
Hepatic artery
Do not confuse the blood supply of the bile duct with that of the cystic duct.
The bile duct has an axial blood supply which is derived from the hepatic artery and from retroduodenal branches of the gastroduodenal artery. Unlike the liver there is no contribution by the portal vein to the blood supply of the bile duct. Damage to the hepatic artery during a difficult
cholecystectomy is a recognised cause of bile duct strictures. In this scenario the distal vessels have been removed as the patient is undergoing a resection.
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What vessel is the origin of the middle rectal artery?
Internal iliac artery
The rectum is supplied by 3 main vessels
. Superior rectal artery from inferior mesenteric artery
. Middle rectal artery from the internal iliac artery
. Inferior rectal artery from the internal pudendal artery
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A 7 year old boy presents with right iliac fossa pain and there is a clinical suspicion that appendicitis is present. From which of the following embryological structures is the appendix derived?
Midgut
The appendix is derived from the midgut
It is derived from the midgut which is why early appendicitis may present with periumbilical pain.
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You decide to take an arterial blood gas from the femoral artery. Where should the needle be inserted to gain the sample?
1-2cm inferiorly to the mid inguinal point
The mid inguinal point is midway between the anterior superior iliac spine and the symphysis pubis
The mid inguinal point in the surface marking for the femoral artery.
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A 25 year old man has an inguinal hernia, which of the following structures must be divided (at open surgery) to gain access to the inguinal canal?
External oblique aponeurosis
This question is asking what structure forms the anterior wall of the inguinal canal. The anterior wall is formed by the external oblique aponeurosis. Once this is divided the canal is entered, the cord can be mobilised and a hernia repair performed. The transversalis fascia and conjoint tendons form the posterior wall and would not routinely be divided to gain access to the inguinal canal itself.
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A 67 year old man has an abdominal aortic aneurysm which displaces the left renal vein. Which branch of the aorta is most likely to be affected at this level?
Superior mesenteric artery
The left renal vein lies behind of the SMA as it branches off the aorta. Whilst juxtarenal AAA may sometimes require the division of the left renal vein, direct involvement of the SMA may require a hybrid surgical bypass and subsequent endovascular occlusion.
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What is the anatomical level of the transpyloric plane?
L1
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The pudendal canal is a fascial canal located on the lateral wall of the ischioanal fossa. In this location, it lies on the inferior border of which of the following muscles?
Obturator internus
The coccygeus, pubococcygeus and iliococcygeus form part of the pelvic diaphragm and are not related to it. The piriformis exits the pelvis via the greater sciatic foramen and is not associated with the canal in the ischiorectal fossa.
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What is the lymphatic drainage of the upper ureter?
Para aortic nodes
The upper ureter drains to the para-aortic nodes, the lower ureter drains to the common iliac nodes.
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A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of the following structures will need to be divided to gain access to the coeliac axis?
Lesser omentum
The lesser omentum will need to be divided. During a radical gastrectomy this forms one of the nodal stations that will need to be taken.
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A 17 year old lady presents with right iliac fossa pain and diagnosed as having acute appendicitis. You take her to theatre to perform a laparoscopic appendicectomy. During the procedure the scrub nurse distracts you and you inadvertently avulse the appendicular artery. The ensuing haemorrhage is likely to be supplied directly from which vessel?
Ileo-colic artery
The appendicular artery is a branch of the ileocolic artery.
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Which of the vessels listed below is the most inferiorly sited single aortic branch?
Median sacral artery
The median sacral artery leaves the aorta a little above its bifurcation. It descends in the midline
anterior to L4 and L5.
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A 63 year old man who smokes heavily presents with dyspepsia. He is tested and found to be positive for helicobacter pylori infection. One evening he has an episode of haematemesis and collapses. What is the most likely vessel to be responsible?
Gastroduodenal artery
He is most likely to have a posteriorly sited duodenal ulcer. These can invade the gastroduodenal artery and present with major bleeding. Although gastric ulcers may invade vessels they do not tend to produce major bleeding of this nature.
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Which of the following nerves is responsible for the cremasteric reflex?
Genitofemoral nerve
The motor and sensory fibres of the genitofemoral nerve are tested in the cremasteric reflex. A small contribution is also played by the ilioinguinal nerve and thus the reflex may be lost following an inguinal hernia repair.
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Which of the following is not found within the deep perineal pouch in an adult male?
Obturator nerve
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A 73 year old lady is admitted with brisk rectal bleeding. Despite attempts at resuscitation the bleeding proceeds to cause haemodynamic compromise. An upper GI endoscopy is normal. A mesenteric angiogram is performed and a contrast blush is seen in the region of the sigmoid colon.
The radiologist decides to embolise the vessel supplying this area. At what spinal level does it leave the aorta?
L3
The inferior mesenteric artery leaves the aorta at L3. It supplies the left colon and sigmoid. Its proximal continuation to communicate with the middle colic artery is via the marginal artery.
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A 53 year old man is undergoing a distal pancreatectomy for trauma. Which of the following vessels is responsible for the arterial supply to the tail of the pancreas?
Splenic artery
Pancreatic head is supplied by the pancreaticoduodenal artery
Pancreatic tail is supplied by branches of the splenic artery
There is an arterial watershed in the supply between the head and tail of the pancreas. The head is supplied by the pancreaticoduodenal artery and the tail is supplied by branches of the splenic artery.
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A 43 year old man is undergoing a right hemicolectomy and the ileo-colic artery is ligated. From which of the following vessels is it derived?
Superior mesenteric artery
The ileocolic artery is a branch of the SMA and supplies the right colon and terminal ileum. The transverse colon is supplied by the middle colic artery. As veins accompany arteries in the mesentery and are lined by lymphatics, high ligation is the norm in cancer resections. The ileo-colic artery branches off the SMA near the duodenum.
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Surgical occlusion of which of these structures, will result in the greatest reduction in hepatic blood flow?
Portal vein
The portal vein transports 70% of the blood supply to the liver, while the hepatic artery provides 30%. The portal vein contains the products of digestion. The arterial and venous blood is dispersed by sinusoids to the central veins of the liver lobules; these drain into the hepatic veins and then into the IVC. The caudate lobe drains directly into the IVC rather than into other hepatic veins.
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A 23 year old man presents with appendicitis. A decision is made to perform an appendicectomy.
The operation commences with a 5cm incision centered on McBurneys point. Which of the following structures will be encountered first during the dissection?
External oblique aponeurosis
The external oblique will be encountered first in this location. The rectus sheath lies more medially.
The external oblique muscle is the most superficial of the abdominal wall muscles. It originates from the 5th to 12th ribs and passes inferomedially to insert into the linea alba, pubic tubercle and anterior half of the iliac crest. It is innervated by the thoracoabdominal nerves (T7-T11) and sub costal nerves.
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A 23 year old man is undergoing an inguinal hernia repair. The surgeons mobilise the spermatic cord and place it in a hernia ring. A small slender nerve is identified superior to the cord. Which nerve is it most likely to be?
Ilioinguinal nerve
The ilioinguinal nerve passes through the inguinal canal and is the nerve most commonly identified during hernia surgery. The genitofemoral nerve splits into two branches, the genital branch passes through the inguinal canal within the cord structures. The femoral branch of the genitofemoral nerve enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. The iliohypogastric nerve pierces the external oblique aponeurosis above the superficial inguinal ring.
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A 45 year old man is undergoing a low anterior resection for a carcinoma of the rectum. Which of the following fascial structures will need to be divided to mobilise the mesorectum from the sacrum and соссух?
Waldeyers fascia
Fascial layers surrounding the rectum:
Anteriorly lies the fascia of Denonvilliers
Posteriorly lies Waldeyers fascia
Waldeyers fascia separates the mesorectum from the sacrum and will need to be divided.
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A 73 year old lady is admitted with acute mesenteric ischaemia. A CT angiogram is performed and a
stenotic lesion is noted at the origin of the superior mesenteric artery. At which of the following levels
does this branch from the aorta?
L1
The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its first
branch the inferior pancreatico-duodenal artery.
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A 72 year old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is located in a juxtarenal location and surgical access to the neck of aneurysm is difficult. Which of the following structures may be divided to improve access?
Left renal vein
The left renal vein will be stretched over the neck of the anuerysm in this location and is not infrequently divided. This adds to the nephrotoxic insult of juxtarenal aortic surgery as a supra renal clamp is also often applied. Deliberate division of the Cisterna Chyli will not improve access and will result in a chyle leak. Division of the transverse colon will not help at all and would result in a high risk of graft infection. Division of the SMA is pointless for a juxtarenal procedure.
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What is the longest part of the male urethra?
Spongy urethra
The spongy urethra is around 15cm long and is the longest part of the male urethra.
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Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of the following dermatomal levels will require blockade?
T12
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At which level does the aorta traverse the diaphragm?
T12
Memory aid:
T8 (8 letters) = vena cava
T10 (10 letters) = oesophagus
T12 (12 letters) = aortic hiatus
Another memory aid (depending upon your learning style):
I ate 10 Eggs At 12’ I (IVC) ate (T8) 10 (T10) eggs (eosophagus) At (aorta) 12 (T12)
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A patient is found to have an ischaemic left colon. Which artery arising from the aorta at around the level of L3 is most likely to account for this situation?
Inferior mesenteric artery
Only the IMA is likely to affect the left side of the colon and originate at L3.
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At which level is the hilum of the left kidney located?
L1
Remember L1 (‘left one’) is the level of the hilum of the left kidney
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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?
S2,3,4
S2, 3, 4 Keeps the poo off the floor
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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You are assisting in an open right adrenalectomy for a large adrenal adenoma. The consultant is distracted and you helpfully pull the adrenal into the wound to improve the view. Unfortunately this is followed by brisk bleeding. The vessel responsible for this is most likely to be:
Inferior vena cava
It drains directly via a very short vessel. If the sutures are not carefully tied then it may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a 6/0 prolene suture.
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A 28 year old lady requires an episiotomy for a ventouse vaginal delivery. Which of the nerves listed below will usually be anaesthetised to allow the episiotomy?
Pudendal
The pudendal nerve innervates the posterior vulval area and is routinely blocked in procedures such as episiotomy.
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An enthusiastic surgical registrar undertakes his first solo splenectomy. The operation is far more difficult than anticipated and the registrar leaves a tube drain to the splenic bed at the end of the procedure. Over the following 24 hours approximately 500ml of clear fluid has entered the drain. Biochemical testing of the fluid is most likely to reveal:
Elevated amylase
During splenectomy the tail of the pancreas may be damaged. The pancreatic duct will then drain into the splenic bed, amylase is the most likely biochemical finding. Glucagon is not secreted into the pancreatic duct.
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A 72 year old man develops a hydrocele which is being surgically managed. As part of the procedure the surgeons divide the tunica vaginalis. From which of the following is this structure derived?
Peritoneum
The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the hydrocele cavity.
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A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani. On examination a polypoidal mass is identified inferior to the dentate line. A biopsy confirms squamous cell carcinoma. To which of the following lymph node groups will the lesion potentially metastasise?
Inguinal
Lesions distal to the dentate line drain to the inguinal nodes. Occasionally this will result in the need for a block dissection of the groin.
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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?
Left renal vein
The renal veins lie most anteriorly, then artery and ureter lies posteriorly.
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A 56 year old lady is due to undergo a left hemicolectomy for carcinoma of the splenic flexure. The surgeons decide to perform a high ligation of the inferior mesenteric vein. Into which of the following does this structure usually drain?
Splenic vein
Beware of ureteric injury in colonic surgery.
The inferior mesenteric vein drains into the splenic vein, this point of union lies close to the
duodenum and this surgical maneouvre is a recognised cause of ileus.
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A man undergoes a high anterior resection for carcinoma of the upper rectum. Which of the following vessels will require ligation?
Inferior mesenteric artery
The IMA is usually divided during anterior resection. Not only is this borne out of oncological
necessity but it also permits sufficient colonic mobilisation for anastomosis.
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A 43 year old lady is due to undergo an axillary node clearance as part of treatment for carcinoma of the breast. Which of the following fascial layers will be divided during the surgical approach to the axilla?
Clavipectoral fascia
The clavipectoral fascia is situated under the clavicular portion of pectoralis major. It protects both the axillary vessels and nodes. During an axillary node clearance for breast cancer the clavipectoral fascia is incised and this allows access to the nodal stations. The nodal stations are; level 1 nodes inferior to pectoralis minor, level 2 lie behind it and level 3 above it. During a Patey Mastectomy surgeons divide pectoralis minor to gain access to level 3 nodes. The use of sentinel node biopsy (and stronger assistants!) have made this procedure far less common.
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Where is a gomphoses type of fibrous joint typically found?
Teeth
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Which of the following statements relating to quadratus lumborum is false?
Causes flexion of the thoracic spine ( Right)
Causes the rib cage to be pulled down
Innervated by anterior primary rami of T12 and L1-3
Attached to the iliac crest
Inserts into the 12th rib
Quadratus lumborum
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3
The rectus abdominis causes flexion of the thoracic spine and therefore the statement suggesting that quaratus lumborum does so is incorrect.
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A 67 year old man is undergoing an angiogram for gastro intestinal bleeding. The radiologist advances the catheter into the coeliac axis. At what spinal level does this vessel typically arise from the aorta?
T12
The coeliac axis lies at T12, it takes an almost horizontal angle off the aorta. It has three major branches
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During a radical gastrectomy for carcinoma of the stomach the surgeons remove the omentum. What is the main source of its blood supply?
Gastroepiploic artery
The vessels supplying the omentum are the omental branches of the right and left gastro-epiploic arteries. The colonic vessels are not responsible for the arterial supply to the omentum. The left gastro-epiploic artery is a branch of the splenic artery and the right gastro-epiploic artery is a terminal branch of the gastroduodenal artery.
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A 45 year old man has a long femoral line inserted to provide CVP measurements. The catheter passes from the common iliac vein into the inferior vena cava. At which of the following vertebral levels will this occur?
L5
The common iliac veins fuse with the IVC at L5.
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At which of the following levels does the inferior vena cava exit the abdominal cavity?
T8
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A 23 year old man complains of severe groin pain several weeks after a difficult inguinal hernia repair. Which nerve is most likely to have been involved?
Ilioinguinal
The ilioinguinal nerve may have been entrapped in the mesh causing a neuroma.
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Which of the positions listed below best describes the location of the coeliac autonomic plexus?
Anterolateral to the aorta
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What is the nerve root value of the external urethral sphincter?
S2, S3, S4
The external urethral sphincter is innervated by branches of the pudendal nerve, therefore the root values are S2, S3, S4.
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A 45 year old man is stabbed in the abdomen and the inferior vena cava is injured. How many functional valves does this vessel usually have?
0
Mnemonic for the Inferior vena cava tributaries: I Like To Rise So High:
lliacs
Lumbar
Testicular
Renal
Suprarenal
Hepatic vein
The lack of valves in the IVC is important clinically when it is cannulated during cardiopulmonary bypass, using separate SVC and IVC catheters, such as when the right atrium is to be opened. Note that there is a non functional valve between the right atrium and inferior vena cava.
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Which of the nerves listed below is responsible for providing voluntary control of the urethral sphincter?
Pudendal nerve
The hypogastric plexuses provide autonomic control of the bladder. However, voluntary control of the urethral sphincter is provided by the pudendal nerve.
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A 53 year old man is to undergo a thyroidectomy. Which nerve is at greatest risk?
Recurrent laryngeal
Recurrent laryngeal nerve injury may complicate thyroid surgery in up to 1-2% of cases.
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Which of the following is the first vessel to branch from the external carotid artery?
Superior thyroid artery
Mnemonic
(Order in which they branch off)Some (sup thyroid)Attendings (Ascending Pharyngeal)Like
(Lingual)Freaking (Facial)Out (Occipital)Potential (Post auricular)Medical (Maxillary)Students (Sup temporal)
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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A 32 year old man is undergoing a splenectomy. Division of which of the following will be necessary during the procedure?
Short gastric vessels
During a splenectomy the short gastric vessels which lie within the gastrosplenic ligament will need to be divided. The splenic flexure of the colon may need to be mobilised. However, it will almost never need to be divided, as this is watershed area that would necessitate a formal colonic resection in the event of division.
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Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen.
He is brought to the emergency department. On examination there is a bullet entry point immediately to the right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most likely to be injured by the bullet?
Fundus of the gallbladder
The fundus of the gallbladder lies at this level and is the most superficially located structure.
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Which of the following anatomical planes separates the prostate from the rectum?
Denonvilliers fascia
The Denonvilliers fascia separates the rectum from the prostate. Waldeyers fascia separates the
rectum from the sacrum
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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?
Aorta
The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery typically arises from the renal vessels.
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A 24 year old man falls and lands astride a manhole cover. He suffers from an injury to the anterior bulbar urethra. Where will the extravasated urine tend to collect?
Connective tissue of the scrotum
This portion of the urethra is contained between the perineal membrane and the membranous layer of the superficial fascia. As these are densely adherent to the ischiopubic rami, extravasated urine cannot pass posteriorly because the 2 layers are continuous around the superficial transverse perineal muscles.
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A 73 year old man presents with symptoms of mesenteric ischaemia. As part of his diagnostic work up a diagnostic angiogram is performed .The radiologist is attempting to cannulate the coeliac axis from the aorta. At which of the following vertebral levels does this is usually originate?
T12
Coeliac trunk branches:
Left Hand Side (LHS)
Left gastric
Hepatic
Splenic
The coeliac axis branches off the aorta at T12.
