6- Abdomen & Pelvic MSQs Only (1)

Question 1

2 of 243

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?

Answer 1

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.

Question 2

3 of 243

What is the lymphatic drainage of the ovaries?

Answer 2

Para-aortic nodes

The lymphatic drainage of the ovary follows the gonadal vessels and drainage is therefore to the
para-aortic nodes.

Question 3

4 of 243

A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated; into which
structure does it drain?

Answer 3

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.

Question 4

5 of 243

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?

Answer 4

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.

Question 5

6 of 243

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?

Answer 5

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.

Question 6

7 of 243

What is the most important structure involved in supporting the uterus?

Answer 6

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.

Question 7

8 of 243

What is the lymphatic drainage of the male spongy urethra?

Answer 7

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.

Question 8

4 of 237

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?

Answer 8

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.

Question 9

3 of 235

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?

Answer 9

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.

Question 10

4 of 235

Which of the structures listed below accompanies the aorta as it traverses the aortic hiatus?

Answer 10

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.

Question 11

7 of 235

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?

Answer 11

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.

Question 12

8 of 235

What vessel is the origin of the middle rectal artery?

Answer 12

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

Question 13

9 of 235

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?

Answer 13

Midgut

The appendix is derived from the midgut

It is derived from the midgut which is why early appendicitis may present with periumbilical pain.

Question 14

10 of 235

You decide to take an arterial blood gas from the femoral artery. Where should the needle be inserted to gain the sample?

Answer 14

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.

Question 15

11 of 235

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?

Answer 15

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.

Question 16

12 of 235
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?

Answer 16

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.

Question 17

13 of 235

What is the anatomical level of the transpyloric plane?

Answer 17

L1

Question 18

15 of 235

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?

Answer 18

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.

Question 19

17 of 235

What is the lymphatic drainage of the upper ureter?

Answer 19

Para aortic nodes

The upper ureter drains to the para-aortic nodes, the lower ureter drains to the common iliac nodes.

Question 20

21 of 235

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?

Answer 20

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.

Question 21

22 of 235

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?

Answer 21

Ileo-colic artery

The appendicular artery is a branch of the ileocolic artery.

Question 22

23 of 235

Which of the vessels listed below is the most inferiorly sited single aortic branch?

Answer 22

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.

Question 23

24 of 235

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?

Answer 23

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.

Question 24

25 of 235

Which of the following nerves is responsible for the cremasteric reflex?

Answer 24

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.

Question 25

28 of 235 Which of the following is not found within the deep perineal pouch in an adult male?

Answer 25

Obturator nerve

Question 26

31 of 235 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?

Answer 26

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.

Question 27

36 of 235 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?

Answer 27

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.

Question 28

35 of 235 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?

Answer 28

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.

Question 29

37 of 235 Surgical occlusion of which of these structures, will result in the greatest reduction in hepatic blood flow?

Answer 29

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.

Question 30

38 of 235 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?

Answer 30

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.

Question 31

39 of 235 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?

Answer 31

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.

Question 32

41 of 235 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?

Answer 32

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.

Question 33

43 of 235 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?

Answer 33

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.

Question 34

44 of 235 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?

Answer 34

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.

Question 35

45 of 235 What is the longest part of the male urethra?

Answer 35

Spongy urethra The spongy urethra is around 15cm long and is the longest part of the male urethra.

Question 36

49 of 235 Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of the following dermatomal levels will require blockade?

Answer 36

T12

Question 36

52 of 235 At which level does the aorta traverse the diaphragm?

Answer 36

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)

Question 37

51 of 235 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?

Answer 37

Inferior mesenteric artery Only the IMA is likely to affect the left side of the colon and originate at L3.

Question 38

53 of 235 At which level is the hilum of the left kidney located?

Answer 38

L1 Remember L1 ('left one') is the level of the hilum of the left kidney

Question 39

54 of 235 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?

Answer 39

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.

Question 40

55 of 235 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:

Answer 40

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.

Question 41

56 of 235 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?

Answer 41

Pudendal The pudendal nerve innervates the posterior vulval area and is routinely blocked in procedures such as episiotomy.

Question 42

57 of 235 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:

Answer 42

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.

Question 43

60 of 235 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?

Answer 43

Peritoneum The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the hydrocele cavity.

Question 43

58 of 235 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?

Answer 43

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.

Question 44

61 of 235 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?

Answer 44

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

Question 45

63 of 235 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?

Answer 45

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.

Question 46

64 of 235 A man undergoes a high anterior resection for carcinoma of the upper rectum. Which of the following vessels will require ligation?

Answer 46

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.

Question 47

65 of 235 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?

Answer 47

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.

Question 48

67 of 235 Where is a gomphoses type of fibrous joint typically found?

Answer 48

Teeth

Question 49

70 of 235 Which of the following statements relating to quadratus lumborum is false?

Answer 49

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.

Question 50

71 of 235 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?

Answer 50

T12 The coeliac axis lies at T12, it takes an almost horizontal angle off the aorta. It has three major branches

Question 51

72 of 235 During a radical gastrectomy for carcinoma of the stomach the surgeons remove the omentum. What is the main source of its blood supply?

Answer 51

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.

Question 52

73 of 235 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?

Answer 52

L5 The common iliac veins fuse with the IVC at L5.

Question 53

74 of 235 At which of the following levels does the inferior vena cava exit the abdominal cavity?

Answer 53

T8

Question 54

75 of 235 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?

Answer 54

Ilioinguinal The ilioinguinal nerve may have been entrapped in the mesh causing a neuroma.

Question 55

76 of 235 Which of the positions listed below best describes the location of the coeliac autonomic plexus?

Answer 55

Anterolateral to the aorta

Question 56

77 of 235 What is the nerve root value of the external urethral sphincter?

Answer 56

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

Question 57

78 of 235 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?

Answer 57

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.

Question 58

79 of 235 Which of the nerves listed below is responsible for providing voluntary control of the urethral sphincter?

Answer 58

Pudendal nerve The hypogastric plexuses provide autonomic control of the bladder. However, voluntary control of the urethral sphincter is provided by the pudendal nerve.

Question 59

81 of 235 A 53 year old man is to undergo a thyroidectomy. Which nerve is at greatest risk?

Answer 59

Recurrent laryngeal Recurrent laryngeal nerve injury may complicate thyroid surgery in up to 1-2% of cases.

Question 60

83 of 235 Which of the following is the first vessel to branch from the external carotid artery?

Answer 60

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.

Question 61

84 of 235 A 32 year old man is undergoing a splenectomy. Division of which of the following will be necessary during the procedure?

Answer 61

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.

Question 62

86 of 235 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?

Answer 62

Fundus of the gallbladder The fundus of the gallbladder lies at this level and is the most superficially located structure.

Question 63

87 of 235 Which of the following anatomical planes separates the prostate from the rectum?

Answer 63

Denonvilliers fascia The Denonvilliers fascia separates the rectum from the prostate. Waldeyers fascia separates the rectum from the sacrum

Question 64

88 of 235 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?

Answer 64

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

Question 65

90 of 235 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?

Answer 65

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.

Question 65

92 of 235 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?

Answer 65

T12 Coeliac trunk branches: Left Hand Side (LHS) Left gastric Hepatic Splenic The coeliac axis branches off the aorta at T12.

Question 66

91 of 235 A 29 year old woman has had a Pfannenstiel incision. She has pain over the inguinal ligament which radiates to the lower abdomen. There is tenderness when the inguinal canal is compressed. Which of the following is most likely to have been affected?

Answer 66

Ilioinguinal nerve

Question 67

93 of 235 A 43 year old man is diagnosed as having a malignancy of the right adrenal gland. The decision is made to resect this via an open anterior approach. Which of the following will be most useful during the surgery?

Answer 67

Mobilisation of the colonic hepatic flexure Mobilisation of the hepatic flexure and right colon are standard steps in open adrenal surgery from an anterior approach. Mobilisation of the liver is seldom required.

Question 68

94 of 235 During a liver resection a surgeon performs a pringles manoeuvre to control bleeding. Which of the following structures will lie posterior to the epiploic foramen at this level?

Answer 68

Inferior vena cava Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the epiploic foramen. The epiploic foramen has the following boundaries: Anteriorly (in the free edge of the lesser omentum): Bile duct to the right, portal vein behind and hepatic artery to the left. PosteriorlyInferior vena cava Inferiorly1st part of the duodenum SuperiorlyCaudate process of the liver

Question 69

98 of 235 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?

Answer 69

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.

Question 70

96 of 235 In which of the following cranial bones does the foramen spinosum lie?

Answer 70

Sphenoid bone The foramen spinosum (which transmits the middle meningeal artery and vein) lies in the sphenoid bone.

Question 71

99 of 235 During a right hemicolectomy the caecum is mobilised. As the bowel is retracted medially a vessel is injured, posterior to the colon. Which of the following is the most likely vessel?

Answer 71

Gonadal vessels The key in this question is that its during the caecal mobilization. The gonadal vessels and ureter are important posterior relations that are at risk during a right hemicolectomy. During latter stages of the procedure, the ileocolic artery and vein are traced along the anterior aspect of the duodenum. At this point it is possible to injure these, the superior mesenteric vein or the middle colic vein, injury to any of these can result in torrential bleeding that is very difficult to control.

Question 72

101 of 235 A 66 year old man is undergoing a left nephro-ureterectomy. The surgeons remove the ureter, which of the following is responsible for the blood supply to the proximal ureter?

Answer 72

Branches of the renal artery The proximal ureter is supplied by branches from the renal artery. For the other feeding vessels

Question 73

103 of 235 Which of the following is not a content of the porta hepatis?

Answer 73

Cystic duct The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The structures in the porta hepatis are: - Portal vein - Hepatic artery - Common hepatic duct These structures divide immediately after or within the porta hepatis to supply the functional left and right lobes of the liver. The porta hepatis is also surrounded by lymph nodes, that may enlarge to produce obstructive jaundice and parasympathetic nervous fibres that travel along vessels to enter the liver.

Question 74

104 of 235 A surgeon is due to perform a laparotomy for perforated duodenal ulcer. An upper midline incision is to be performed. Which of the following structures is the incision most likely to divide?

Answer 74

Linea alba Upper midline abdominal incisions will involve the division of the linea alba. Division of muscles will not usually improve access in this approach and they would not be routinely encountered during this incision.

Question 75

105 of 235 A 59 year old man is undergoing an extended right hemicolectomy for a carcinoma of the splenic flexure of the colon. The surgeons divide the middle colic vein close to its origin. Into which of the following structures does this vessel primarily drain?

Answer 75

Superior mesenteric vein The middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur and be difficult to control.

Question 76

106 of 235 What is the lymphatic drainage of the female urethra?

Answer 76

Internal iliac nodes The entire female urethra drains to the internal iliac nodes.

Question 77

107 of 235 A 23 year old man is stabbed in the chest approximately 10cm below the right nipple. In the emergency department a abdominal ultrasound scan shows a large amount of intraperitoneal blood. Which of the following statements relating to the likely site of injury is untrue?

Answer 77

The quadrate lobe is contained within the functional right lobe. The right lobe of the liver is the most likely site of injury. Therefore the answer is B as the quadrate lobe is functionally part of the left lobe of the liver. The liver is largely covered in peritoneum. Posteriorly there is an area devoid of peritoneum (the bare area of the liver). The right lobe of the liver has the largest bare area (and is larger than the left lobe).

Question 77

109 of 235 Which of the following nerves passes through the greater sciatic foramen and innervates the perineum?

Answer 77

Pudendal 3 divisions of the pudendal nerve: Rectal nerve Perineal nerve Dorsal nerve of penis/ clitoris All these pass through the greater sciatic foramen. The pudendal nerve innervates the perineum. It passes between piriformis and coccygeus medial to the sciatic nerve.

Question 77

Question 112 of 235 A 53 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. From which embryological structure is this region of the gastrointestinal tract derived?

Answer 77

Hind gut The left colon is embryologically part of the hind gut. Which accounts for its separate blood supply via the IMA.

Question 78

113 of 235 You excitedly embark on your first laparoscopic cholecystectomy and during the operation the anatomy of Calots triangle is more hostile than anticipated. Whilst trying to apply a haemostatic clip you avulse the cystic artery. This is followed by brisk haemorrhage. From which source is this most likely to originate ?

Answer 78

Right hepatic artery The cystic artery is a branch of the right hepatic artery. There are recognised variations in the anatomy of the blood supply to the gallbladder. However, the commonest situation is for the cystic artery to branch from the right hepatic artery.

Question 79

114 of 235 A 43 year old man suffers a pelvic fracture which is complicated by an injury to the junction of the membranous urethra to the bulbar urethra. In which of the following directions is the extravasated urine most likely to pass?

Answer 79

Anteriorly into the connective tissues surrounding the scrotum The superficial perineal pouch is a compartment bounded superficially by the superficial perineal fascia, deep by the perineal membrane (inferior fascia of the urogenital diaphragm), and laterally by the ischiopubic ramus. It contains the crura of the penis or clitoris, muscles, viscera, blood vessels, nerves, the proximal part of the spongy urethra in males, and the greater vestibular glands in females. When urethral rupture occurs as in this case the urine will tend to pass anteriorly because the fascial condensations will prevent lateral and posterior passage of the urine.

Question 80

115 of 235 During the course of a radical gastrectomy the surgeons detach the omentum and ligate the right gastro-epiploic artery. From which vessel does it originate?

Answer 80

Gastroduodenal artery The gastroduodenal artery arises at the superior part of the duodenum and descends behind it to terminate at its lower border. It terminates by dividing into the right gastro-epiploic artery and the superior pancreaticoduodenal artery. The right gastro-opiploic artery passes to the left and passes between the layers of the greater omentum to anastomose with the left gastro-epiploic artery.

Question 80

117 of 235 Through which of the following foramina does the genital branch of the genitofemoral nerve exit the abdominal cavity?

Answer 80

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).

Question 81

119 of 235 A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the uterine body. To which nodal region will the tumour initially metastasise?

Answer 81

Iliac lymph nodes Tumours of the uterine body will tend to spread to the iliac nodes initially. Tumour expansion crossing different nodal margins this is of considerable clinical significance, if nodal clearance is performed during a Wertheims type hysterectomy.

Question 82

120 of 235 Which of the following structures is not located in the superficial perineal space in females?

Answer 82

Pudendal nerve The pudendal nerve is located in the deep perineal space and then branches to innervate more superficial structures.

Question 83

121 of 235 Which of the following is not a branch of the hepatic artery?

Answer 83

Pancreatic artery The pancreatic artery is a branch of the splenic artery.

Question 84

122 of 235 Which of the following structures does not pass close to the piriformis muscle in the greater sciatic foramen?

Answer 84

Obturator nerve The obturator nerve does not pass through the greater sciatic foramen.

Question 85

123 of 235 A 56 year old man is undergoing a right nephrectomy. The surgeons divide the renal artery. At what level does this usually branch off the abdominal aorta?

Answer 85

L2 The renal arteries usually branch off the aorta on a level with L2.

Question 86

125 of 235 A 22 year old man presents with appendicitis. At operation the appendix is retrocaecal and difficult to access. Division of which of the following anatomical structures should be undertaken?

Answer 86

Lateral peritoneal attachments of the caecum The commonest appendiceal location is retrocaecal. Those struggling to find it at operation should trace the tenia to the caecal pole where the appendix is located. If it cannot be mobilised easily then division of the lateral caecal peritoneal attachments (as for a right hemicolectomy) will allow caecal mobilisation and facilitate the procedure.

Question 87

126 of 235 A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum. What is the most likely explanation?

Answer 87

Damage to the hypogastric plexus during mobilisation of the inferior mesenteric artery Autonomic nerve injury is the most common cause.

Question 88

127 of 235 A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To which of the following lymph nodes will the tumour drain primarily?

Answer 88

Internal iliac The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first site.

Question 89

Question 129 of 235 A 73 year old man undergoes a sub total oesophagectomy with anastomosis of the stomach to the cervical oesophagus. Which vessel will be primarily responsible for the arterial supply to the oesophageal portion of the anastomosis?

Answer 89

Inferior thyroid artery The cervical oesophagus is supplied by the inferior thyroid artery. The thoracic oesophagus (removed in this case) is supplied by direct branches from the thoracic aorta.

Question 90

131 of 235 A 28 year old man has sustained a non salvageable testicular injury to his left testicle. The surgeon decides to perform an orchidectomy and divides the left testicular artery. From which of the following does this vessel originate?

Answer 90

Abdominal aorta The testicular artery is a branch of the abdominal aorta.

Question 91

132 of 235 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?

Answer 91

Gerotas fascia Waldeyers fascia- Posterior ano-rectum Sibsons fascia- Lung apex Bucks fascia- Base of penis Gerotas fascia- Surrounding kidney Denonvilliers fascia- Between rectum and prostate

Question 92

135 of 235 Which of the following structures is not directly related to the right adrenal gland?

Answer 92

Right renal vein The right renal vein is very short and lies more inferiorly.

Question 93

136 of 235 Which of the following aortic branches leaves the aorta approximately 1cm below the coeliac axis?

Answer 93

Superior mesenteric artery The SMA leaves the aorta approximately 1cm below the coeliac axis. This is usually a level of L1. It is crossed anteriorly by the splenic vein and the body of the pancreas. It runs downwards and forwards anterior to the uncinate process.

Question 94

137 of 235 Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following?

Answer 94

Abdominal oesophagus The fundus of the stomach is a posterior relation. The pylorus lies more inferolaterally. During a total gastrectomy division of the ligaments holding the left lobe of the liver will facilitate access to the proximal stomach and abdominal oesophagus. This manoeuvre is seldom beneficial during a distal gastrectomy.

Question 95

140 of 235 At what level does the aorta bifurcate into the left and right common iliac arteries?

Answer 95

L4 The aorta typically bifurcates at L4. This level is usually fairly constant and is often tested in the exam.

Question 96

143 of 235 A 32 year old man presents with an inguinal hernia and undergoes an open surgical repair. The surgeons decide to place a mesh on the posterior wall of the inguinal canal to complete the repair, which of the following structures will lie posterior to the mesh?

Answer 96

Transversalis fascia Starting from superior, moving around in order to posterior: Superior wall (roof): 2 Muscles:Internal oblique, transversus abdominis Anterior wall: 2 Aponeuroses: Aponeurosis of external oblique, Aponeurosis of internal oblique Lower wall (floor): 2 Ligaments: Inguinal Ligament, Lacunar Ligament Posterior wall: 2Ts: Transversalis fascia, Conjoint Tendon This is actually quite a straightforward question. It is simply asking for the structure that forms the posterior wall of the inguinal canal. This is composed of the transversalis fascia, the conjoint tendon and more laterally the deep inguinal ring.

Question 97

146 of 235 At which of the following spinal levels does the oesophagus pass through the diaphragm into the abdominal cavity?

Answer 97

T10 The oesophagus passes into the abdomen at T10.

Question 98

147 of 235 A 22 year old man is involved in a fight outside a nightclub. He is stabbed in the back, on the left side, approximately 3cm below the 12th rib in the mid scapular line. The structure most likely to be injured first as a result is the:

Answer 98

Left kidney The left kidney lies in this location and is the most likely structure to be injured. The Spleen lies more superiorly, and the left adrenal and ureter are unlikely to be injured in isolation.

Question 98

148 of 235 A 23 year old man is undergoing a hernia repair and the mesh is to be sutured to the inguinal ligament. From which of the following does the inguinal ligament arise?

Answer 98

External oblique aponeurosis The inguinal ligament is formed by the external oblique aponeurosis. It runs from the pubic tubercle to the anterior superior iliac spine.

Question 99

149 of 235 A 56 year old man is undergoing a high anterior resection. Which of the following structures is at greatest risk of injury in this procedure?

Answer 99

Left ureter A careless surgeon may damage all of these structures. However, the structure at greatest risk and most frequently encountered is the left ureter.

Question 100

150 of 235 A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which of the following structures will be occluded in this manoeuvre?

Answer 100

Portal vein The portal vein, hepatic artery and common bile duct are occluded.

Question 101

152 of 235 On inspecting the caecum, which of the following structures is most likely to be identified at the point at which all the tenia coli converge?

Answer 101

The tenia coli converge at the base of the appendix.

Question 102

154 of 235 What is the most inferior anterior aortic branch?

Answer 102

Inferior mesenteric artery The IMA leaves the front of the aorta usually about 3 to 4cm superior to its bifurcation. The median sacral is not an anterior branch.

Question 103

155 of 235 Which of the following structures lies most posteriorly at the porta hepatis?

Answer 103

Portal vein The portal vein is the most posterior structure at the porta hepatis. The common bile duct is a continuation of the common hepatic duct and is formed by the union of the common hepatic duct and the cystic duct.

Question 104

156 of 235 A 76 year old man is undergoing an abdominal aortic aneurysm repair. The surgeons occlude the aorta with two clamps, the inferior clamp being placed at the point of aortic bifurcation. Which of the following vertebral bodies will lie posterior to the clamp at this level?

Answer 104

L4 The aorta bifurcates at L4. An important landmark that is tested frequently.

Question 104

157 of 235 Which of the following statements relating to the greater omentum is false?

Answer 104

It is less well developed in children under 5. It has no relationship to the lesser sac. (RIGHT) It contains the gastroepiploic arteries. Has an attachment to the transverse colon. It may be a site of metastatic disease in ovarian cancer. It is connected with the lesser sac and the transverse colon. This plane is entered when performing a colonic resection. It is a common site of metastasis in many visceral malignancies.

Question 105

158 of 235 A 48 year old man with newly diagnosed hypertension is found to have a phaeochromocytoma of the left adrenal gland and is due to undergo a laparoscopic left adrenalectomy. Which of the following structures is not directly related to the left adrenal gland?

Answer 105

Lesser curvature of the stomach The left adrenal gland is slightly larger than the right. It is crescent in shape and its concavity is adapted to the medial border of the upper part of the left kidney. The upper area is covered by peritoneum of the omental bursa which separates it from the cardia of the stomach. The lower area is in contact with the pancreas and splenic artery and is not covered by peritoneum. On the anterior surface is a hilum from which the suprarenal vein emerges. The lateral aspect rests on the kidney. The medial is small and is on the left crus of the diaphragm.

Question 106

160 of 235 An 18 year old boy is undergoing an appendicectomy for appendicitis. At which of the following locations is the appendix most likely to be found?

Answer 106

Retrocaecal Most appendixes lie in the retrocaecal position. If a retrocaecal appendix is difficult to remove then mobilisation of the right colon significantly improves access.

Question 107

161 of 235 A 56 year old man is undergoing a pancreatectomy for carcinoma. During resection of the gland which of the following structures will the surgeon not encounter posterior to the pancreas itself?

Answer 107

Gastroduodenal artery The gastroduodenal artery divides into the gastro-epiploic and pancreaticoduodenal arteries at the superior aspect of the pancreas.

Question 108

162 of 235 From which structure is the central tendon of the diaphragm derived?

Answer 108

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.

Question 109

163 of 235 A 55 year old man is admitted with a brisk haematemesis. He is taken to the endoscopy department and an upper GI endoscopy is performed by the gastroenterologist. He identifies an ulcer on the posterior duodenal wall and spends an eternity trying to control the bleeding with all the latest haemostatic techniques. He eventually asks the surgeons for help. A laparotomy and anterior duodenotomy are performed, as the surgeon opens the duodenum a vessel is spurting blood into the duodenal lumen. From which of the following does this vessel arise?

Answer 109

Common hepatic artery The vessel will be the gastroduodenal artery, this arises from the common hepatic artery.

Question 110

164 of 235 Which of the following is not a content of the rectus sheath?

Answer 110

Internal iliac artery The rectus sheath also contains: superior epigastric vein inferior epigastric artery

Question 111

165 of 235 Which of the following vessels does not drain directly into the inferior vena cava?

Answer 111

Superior mesenteric vein The superior mesenteric vein drains into the portal vein. The right and left hepatic veins drain into it directly, this can account for major bleeding in more extensive liver shearing type injuries.

Question 112

166 of 235 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?

Answer 112

External spermatic fascia The layers that will be encountered are (in order): 1. Skin 2. Dartos fascia and muscle 3. External spermatic fascia 4. Cremasteric muscle and fascia 5. Internal spermatic fascia 6. Parietal layer of the tunica vaginalis The layers of the spermatic cord and scrotum are a popular topic in the MRCS exam. A mnemonic which may help: Some Damned Examiner Called It The Testes (skin dartos external fascia cremaster internal fascia tunica Testes)

Question 113

167 of 235 A 19 year old man undergoes an open inguinal hernia repair. The cord is mobilised and the deep inguinal ring identified. Which of the following structures forms its lateral wall?

Answer 113

Transversalis fascia The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric vessels form its inferomedial wall.

Question 114

168 of 235 During an inguinal hernia repair the surgeon identifies a small nerve whilst mobilising the cord structures at the level of the superficial inguinal ring. Which nerve is this most likely to be?

Answer 114

Ilioinguinal llioinguinal nerve entrapment may be a cause of neuropathic pain following inguinal hernia surgery. The ilioinguinal nerve passes through the superfical inguinal ring and is routinely encountered when exploring the inguinal canal during hernia surgery. The iliohypogastric nerve pierces the aponeurosis of the external oblique muscle superior to the superficial inguinal ring.

Question 115

169 of 235 What is the lymphatic drainage of the membranous urethra?

Answer 115

Internal iliac nodes The prostatic and membranous urethra drain to the internal iliac nodes.

Question 116

170 of 235 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?

Answer 116

Pudendal S2,3,4 keeps the poo up off the floor - POOdendal nerve 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.

Question 117

171 of 235 During a difficult thyroidectomy haemorrhage is noted from the thyroidea ima vessel. From which structure does this vessel usually arise?

Answer 117

Brachiocephalic artery Rhyme isthmus location: Rings 2,3,4 make the isthmus floor This accessory vessel which usually lies at the inferior aspect of the gland is derived either from the brachiocephalic artery or the arch of the aorta.

Question 117

172 of 235 Which of the following is not a branch of the abdominal aorta?

Answer 117

Superior phrenic artery Mnemonic for the Descending abdominal aorta branches from diaphragm to iliacs: 'Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin': Phrenic [inferior] Celiac Superior mesenteric Suprarenal [middle] Renal Testicular ['in men' only] Lumbars Inferior mesenteric Sacral The superior phrenic artery branches from the aorta in the thorax.

Question 118

173 of 235 A 23 year old man is admitted with a suspected ureteric colic. A KUB style x-ray is obtained. In which of the following locations is the stone most likely to be visualised?

Answer 118

The tips of the transverse processes between L2 and L5 The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they may also be identified over the sacro-iliac joints.

Question 119

174 of 235 In a patient with an ectopic kidney where is the adrenal gland most likely to be located?

Answer 119

In its usual position Because the kidney is present, rather than absent, the adrenal will usually develop and in the normal location.

Question 120

177 of 235 A 55 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. Which of the following vessels directly supplies the prostate?

Answer 120

Inferior vesical artery The arterial supply to the prostate gland is from the inferior vesical artery, it is a branch of the prostatovesical artery. The prostatovesical artery usually arises from the internal pudendal and inferior gluteal arterial branches of the internal iliac artery.

Question 121

181 of 235 From which embryological structure is the ureter derived?

Answer 121

Mesonephric duct The ureter develops from and outpouching that arises from the mesonephric duct. The mesonephric duct is associated with the metanephric duct that develops within the metenephrogenic blastema. This forms the site of the ureteric bud which branches off the mesonephric duct.

Question 122

185 of 235 A 62 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. The registrar commences mobilisation of the left colon by pulling downwards and medially. Blood soon appears in the left paracolic gutter. The most likely source of bleeding is the:

Answer 122

Spleen The spleen is commonly torn by traction injuries in colonic surgery. The other structures are associated with bleeding during colonic surgery but would not manifest themselves as blood in the paracolic gutter prior to incision of the paracolonic peritoneal edge.

Question 123

188 of 235 Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?

Answer 123

Spongiose part Bucks fascia is a layer of deep fascia that covers the penis it is continuous with the external spermatic fascia and the penile suspensory ligament. The membranous part of the urethra may partially pass through Bucks fascia as it passes into the penis. However, the spongiose part of the urethra is contained wholly within Bucks fascia.

Question 123

186 of 235 A 53 year old man with a chronically infected right kidney is due to undergo a nephrectomy. Which of the following structures would be encountered first during a posterior approach to the hilum of the right kidney?

Answer 123

Ureter The ureter is the most posterior structure at the hilum of the right kidney and would therefore be encountered first during a posterior approach.

Question 124

189 of 235 A 48 year old lady is undergoing a left sided adrenalectomy for an adrenal adenoma. The superior adrenal artery is injured and starts to bleed, from which of the following does this vessel arise?

Answer 124

Inferior phrenic artery The superior adrenal artery is a branch of the inferior phrenic artery.

Question 124

190 of 235 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?

Answer 124

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

Question 125

191 of 235 A 73 year old man has a large abdominal aortic aneurysm. During a laparotomy for planned surgical repair the surgeons find the aneurysm is far more proximally located and lies near the origin of the SMA. During the dissection a vessel lying transversely across the aorta is injured. What is this vessel most likely to be?

Answer 125

Left renal vein The left renal vein runs across the surface of the aorta and may require deliberate ligation during juxtarenal aneurysm repair.

Question 126

192 of 235 A 18 year old man presents with an indirect inguinal hernia and undergoes surgery. The deep inguinal ring is exposed and held with a retractor at its medial aspect. Which structure is most likely to lie under the retractor?

Answer 126

Inferior epigastric artery Boundaries of the deep inguinal ring: Superolaterally - transversalis fascia Inferomedially - inferior epigastric artery The deep inguinal ring is closely related to the inferior epigastric artery. The inferior epigastric artery forms part of the structure referred to as Hesselbach's triangle.

Question 127

194 of 235 In a patient with a carcinoma of the distal sigmoid colon, what is the most likely source of its blood supply?

Answer 127

Inferior mesenteric artery During a high anterior resection of such tumours, the inferior mesenteric artery is ligated. Note that the branches (mainly middle rectal branch) of the internal iliac artery are important in maintaining vascularity of the rectal stump and hence the integrity of the anastomoses.

Question 128

195 of 235 A patient is due to undergo a right hemicolectomy for a carcinoma of the caecum. Which of the following vessels will require high ligation to provide optimal oncological control?

Answer 128

Ileo-colic artery The ileo - colic artery supplies the caecum and would require high ligation during a right hemicolectomy. The middle colic artery should generally be preserved when resecting a caecal lesion. This question is essentially asking you to name the vessel supplying the caecum. The SMA does not directly supply the caecum, it is the ileocolic artery which does this.

Question 129

196 of 235 A 72 year old man is undergoing a repair of an abdominal aortic aneurysm. The aorta is cross clamped both proximally and distally. The proximal clamp is applied immediately inferior to the renal arteries. Both common iliac arteries are clamped distally. A longitudinal aortotomy is performed. After evacuating the contents of the aneurysm sac a significant amount of ongoing bleeding is encountered. This is most likely to originate from:

Answer 129

Lumbar arteries The lumbar arteries are posteriorly sited and are a common cause of back bleeding during aortic surgery. The other vessels cited all exit the aorta in the regions that have been cross clamped.

Question 130

197 of 235 A 63 year old man undergoes a radical cystectomy for carcinoma of the bladder. During the procedure there is considerable venous bleeding. What is the primary site of venous drainage of the urinary bladder?

Answer 130

Vesicoprostatic venous plexus The urinary bladder has a rich venous plexus surrounding it, this drains subsequently into the internal iliac vein. The vesicoprostatic plexus may be a site of considerable venous bleeding during cystectomy.

Question 131

198 of 235 A 60 year old female is undergoing a Whipples procedure for adenocarcinoma of the pancreas. As the surgeons begin to mobilise the pancreatic head they identify a large vessel passing inferiorly over the anterior aspect of the uncinate process. What is it likely to be?

Answer 131

Superior mesenteric artery The superior mesenteric artery arises from the aorta and passes anterior to the lower part of the pancreas. Invasion of this structure is a relative contra indication to resectional surgery.

Question 132

199 of 235 An 18 year old man is undergoing an orchidectomy via a scrotal approach. The surgeons mobilise the spermatic cord. From which of the following is the outermost layer of this structure derived?

Answer 132

External oblique aponeurosis The outermost covering of the spermatic cord is derived from the external oblique aponeurosis.This layer is added as the cord passes through the superficial inguinal ring.

Question 133

200 of 235 A 53 year old male presents with a carcinoma of the transverse colon. Which of the following structures should be ligated close to their origin to maximise clearance of the tumour?

Answer 133

Middle colic artery The middle colic artery supplies the transverse colon and requires high ligation during cancer resections. It is a branch of the superior mesenteric artery.

Question 134

201 of 235 Which of the following structures does not lie posterior to the right kidney?

Answer 134

10th rib The 8th and10th ribs lie more superiorly. The 12th rib is a closer relation posteriorly. Quadratus lumborum runs between the posterior part of the iliac crest, iliolumbar ligament and the transverse processes of the lower lumbar vertebrae to the medial part of the lower border of the last rib and transverse process of the upper lumbar vertebrae. In these last two locations it is posterior to the kidney.

Question 135

202 of 235 A 56 year old man is undergoing a radical nephrectomy via a posterior approach. Which of the following structures is most likely to be encountered during the operative approach?

Answer 135

12th rib The 11th and 12th ribs lie posterior to the kidneys and may be encountered during a posterior approach. A pneumothorax is a recognised complication of this type of surgery.

Question 136

203 of 235 How many unpaired branches leave the abdominal aorta to supply the abdominal viscera?

Answer 136

Three There are three unpaired branches to the abdominal viscera. These include the coeliac axis, the SMA and IMA. Branches to the adrenals, renal arteries and gonadal vessels are paired. The fourth unpaired branch of the abdominal aorta, the median sacral artery, does not directly supply the abdominal viscera.

Question 137

204 of 235 A 45 year old man presents with bilateral inguinal hernias. The surgical team decide to repair these laparoscopically through an extraperitoneal approach. Through an infraumbilical incision the surgeons displace the inferior aspect of the rectus abdominis muscle anteriorly and place a prosthetic mesh into the area to repair the hernias. Which structure will lie posterior to the mesh?

Answer 137

Peritoneum During a TEP repair of inguinal hernia the only structure to lie posterior to the mesh is peritoneum. The question is really only asking which structure lies posterior to the rectus abdominis muscle. Since this region is below the arcuate line, the transversalis fascia and peritoneum lie posterior to it. Bucks fascia lies in the penis.

Question 138

205 of 235 During embryological development, which of the following represent the correct origin of the pancreas?

Answer 138

Ventral and dorsal endodermal outgrowths of the duodenum The pancreas develops from a ventral and dorsal endodermal outgrowth of the duodenum. The ventral arises close to, or in common with the hepatic diverticulum, and the larger, dorsal outgrowth arises slightly cranial to the ventral extending into the mesoduodenum and mesogastrium. When the buds eventually fuse the duct of the ventral rudiment becomes the main pancreatic duct.

Question 139

206 of 235 A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?

Answer 139

Lienorenal ligament The lienorenal ligament lies most posteriorly. The antero-lateral connection is via the phrenicocolic ligament. Anteriorly the gastro splenic ligament. These structures condense around the vessels at the splenic hilum.

Question 140

Question 206 of 235 A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?

Answer 140

Lienorenal ligament The lienorenal ligament lies most posteriorly. The antero-lateral connection is via the phrenicocolic ligament. Anteriorly the gastro splenic ligament. These structures condense around the vessels at the splenic hilum.

Question 141

207 of 235 Which of the following statements about the spleen is false?

Answer 141

The hilum contains the splenic vessels. The spleen is derived from endodermal tissue.(RIGHT) The white pulp has immune function. The colon lies inferiorly. Weighs 150g. 1,3,5,7,9,11 (odd numbers up to 11) The spleen is: 1 inch thick, 3 inches wide, 5 inches long, weighs 7oz (150-200g), lies between the 9th and 11th ribs Most of the gut is derived endodermally except for the spleen which is from mesenchymal tissue.

Question 141

208 of 235 Which of the following structures is not at the level of the transpyloric plane?

Answer 141

Cardioesophageal junction Cardiooesophageal junction level = T11 A knowledge of this anatomic level is commonly tested. The oesophagus extends from C6 (the lower border of the cricoid cartilage) to T11 at the cardioesophageal junction. Note that in the neonate the oesophagus extends from C4 or C5 to T9.

Question 142

209 of 235 A 45 year old man is undergoing a left hemicolectomy. As the surgeons mobilise the left colon they identify a tubular structure lying at the inferior aspect of psoas major. What is it most likely to be?

Answer 142

Left ureter The left ureter lies posterior to the left colon. The sigmoid colon and upper rectum may be more closely related to the iliac vessels. These are not typically found above L4.

Question 143

210 of 235 A 42 year old woman is due to undergo a left nephroureterectomy for a transitional cell carcinoma involving the ureter. Which of the following structures is not related to the left ureter?

Answer 143

Round ligament of the uterus The ureter is not related to the round ligament of the uterus, it is related to the broad ligament and is within 1.5cm of the supravaginal part of the cervix.

Question 144

213 of 235 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?

Answer 144

Rectus abdominis muscle Direct inguinal hernias pass through Hesselbachs triangle (although this is of minimal clinical significance!). Its medial boundary is the rectus muscle.

Question 145

Question 212 of 235 A 28 year old man is undergoing an appendicectomy. The external oblique aponeurosis is incised and the underlying muscle split in the line of its fibres. At the medial edge of the wound is a tough fibrous structure. Entry to this structure will most likely encounter which of the following?

Answer 145

Rectus abdominis This structure will be the rectus sheath and when entered the rectus abdominis muscle will be encountered.

Question 146

214 of 235 Where are accessory spleens not found?

Answer 146

Ureter Accessory spleens - 10% population - 1 cm size - locations: hilum of the spleen, tail of the pancreas, along the splenic vessels, in the gastrosplenic ligament, the splenorenal ligament, the walls of the stomach or intestines, the greater omentum, the mesentery, the gonads

Question 146

216 of 235 A 56 year old man is undergoing an anterior resection for a carcinoma of the rectum. Which of the structures below is least likely to be encountered during the mobilisation of the anterior rectum?

Answer 146

Middle sacral artery With the exception of the middle sacral artery all of the other structures lie anterior to the rectum. They may all be palpated during digital rectal examination.

Question 147

219 of 235 The inferior aspect of the vagina drains to which of the following lymph node groups?

Answer 147

Superficial inguinal nodes

Question 147

221 of 235 A 25 year old man is being catheterised, prior to a surgical procedure. As the catheter enters the prostatic urethra which of the following changes will occur?

Answer 147

Resistance will decrease The prostatic urethra is much wider than the membranous urethra and therefore resistance will decrease. The prostatic urethra is inclined superiorly.

Question 148

Question 223 of 235 A 78 year old man develops a carcinoma of the scrotum. To which of the following lymph node groups may the tumour initially metastasise?

Answer 148

Inguinal The scrotum is drained by the inguinal nodes.

Question 149

226 of 235 An 22 year old soldier is shot in the abdomen and amongst his various injuries is a major disruption to the abdominal aorta. There is torrential haemorrhage and the surgeons decide to control the aorta by placement of a vascular clamp immediately inferior to the diaphragm. Which of the following vessels may be injured in this maneouvre?

Answer 149

Inferior phrenic arteries As the first branches of the abdominal aorta the inferior phrenic arteries are at greatest risk. The superior phrenic arteries lie in the thorax. The potential space at the level of the diaphragmatic hiatus is a potentially useful site for aortic occlusion. However, leaving the clamp applied for more than about 10 -15 minutes usually leads to poor outcomes.

Question 150

227 of 235 Which of the following statements relating to the gallbladder is untrue?

Answer 150

Cholecystokinin causes relaxation of the gallbladder CCK causes gallbladder contraction.

Question 151

228 of 235 Which of the following nerves is the primary source of innervation to the anterior scrotal skin?

Answer 151

Ilioinguinal nerve The pudendal nerve may innervate the posterior skin of the scrotum. The anterior innervation of the scrotum is primarily provided by the ilioinguinal nerve. The genital branch of the genitofemoral nerve provides a smaller contribution.

Question 152

229 of 235 The transversalis fascia contributes to which of the following?

Answer 152

Deep inguinal ring The internal spermatic fascia (derived from transversalis fascia) invests: Ductus deferens Testicular vessels The principal outpouching of the transversalis fascia is the internal spermatic fascia. The mouth of the outpouching is the deep inguinal ring.

Question 152

231 of 235 A 73 year old lady is admitted with right iliac fossa pain. A plain abdominal x-ray is taken and the caecal diameter measured. Which of the following caecal diameters is pathological?

Answer 152

10cm 8 cm is still within normal limits. However, caecal diameters of 9 and 10 are pathological and should prompt further investigation.

Question 153

Question 233 of 235 Which of the following options in relation to the liver is true?

Answer 153

The caudate lobe is superior to the porta hepatis 'VC goes with VC' The ligamentun Venosum and Caudate is on same side as Vena Cava [posterior]. Ligamentum venosum is posterior to the liver. The portal triad contains the portal vein rather than the hepatic vein. There is the 'bare area of the liver' created by a void due to the coronary ligament layers being widely separated. There are sympathetic and parasympathetic nerves in the porta hepatis.

Question 154

234 of 235 The following statements regarding the rectus abdominis muscle are true except:

Answer 154

- It runs from the symphysis pubis to the xiphoid process - Its nerve supply is from the ventral rami of the lower 6 thoracic nerves - It has collateral supply from both superior and inferior epigastric vessels - It lies in a muscular aponeurosis throughout its length(RIGHT) - It has a number of tendinous intersections that penetrate through the anterior layer of the muscle Rectus abdominis - Arises from the pubis. - Inserts into 5th, 6th, 7th costal cartilages. - The muscle lies in the rectal sheath, which also contains the superior and inferior epigastric artery and vein. - Action: flexion of thoracic and lumbar spine. - Nerve supply: anterior primary rami of T7-12. The aponeurosis is deficient below the arcuate line.

Question 155

235 of 235 During liver mobilisation for a cadaveric liver transplant the hepatic ligaments will require mobilisation. Which of the following statements relating to these structures is untrue?

Answer 155

- Lesser omentum arises from the porta hepatis and passes the lesser curvature of the stomach - The falciform ligament divides into the left triangular ligament and coronary ligament - The liver has an area devoid of peritoneum - The coronary ligament is attached to the liver - The right triangular ligament is an early branch of the left triangular ligament(RIGHT) The right triangular ligament is a continuation of the coronary ligament.