6- Abdomen & Pelvic MSQs Only (2) Flashcards
1
Q
1- The transversalis fascia contributes to which of the following?
A
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.
2
Q
2- Which of the following nerves is the primary source of innervation to the anterior scrotal skin?
A
llioinguinal 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.
3
Q
3- Which of the following statements relating to the gallbladder is untrue?
A
Cholecystokinin causes relaxation of the gallbladder
CCK causes gallbladder contraction.
4
Q
4-The inferior aspect of the vagina drains to which of the following lymph node groups?
A
Superficial inguinal nodes
5
Q
5- Which of the following options in relation to the liver is true?
A
-Ligamentum venosum is an anterior relation of the liver
-The portal triad comprises the hepatic artery, hepatic vein and tributary of the bile duct
-The liver is completely covered by peritoneum
-There are no nerves within the porta hepatis
-The caudate lobe is superior to the porta hepatis( Right)
‘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.
6
Q
6- 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?
A
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.
7
Q
7- 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?
A
Resistance will decrease
The prostatic urethra is much wider than the membranous urethra and therefore resistance will decrease. The prostatic urethra is inclined superiorly.
8
Q
8- 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?
A
10cm
8 cm is still within normal limits. However, caecal diameters of 9 and 10 are pathological and should prompt further investigation.
9
Q
9- A 78 year old man develops a carcinoma of the scrotum. To which of the following lymph node groups may the tumour initially metastasise?
A
Inguinal
The scrotum is drained by the inguinal nodes.
10
Q
10- 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 toughfibrous structure. Entry to this structure will most likely encounter which of the following?
A
Rectus abdominis
This structure will be the rectus sheath and when entered the rectus abdominis muscle will be encountered.
11
Q
12- A 35 year old man presents to the surgical clinic with a suspected direct inguinal hernia. These will pass through Hesselbach’s triangle. Which of the following forms the medial edge of this structure?
A
Rectus abdominis muscle
Direct inguinal hernias pass through Hesselbachs triangle (although this is of minimal clinical significance!). Its medial boundary is the rectus muscle.
11
Q
11- The following statements regarding the rectus abdominis muscle are true except:
A
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)
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.
12
Q
13- 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?
A
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.
13
Q
14- Where are accessory spleens not found?
A
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
14
Q
15- 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?
A
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.
15
Q
16- 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?
A
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.
16
Q
17- Which of the following structures is not at the level of the transpyloric plane?
A
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.
17
Q
18- A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?
A
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.
18
Q
19- During embryological development, which of the following represent the correct origin of the pancreas?
A
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.
19
Q
20- A 20 year old man undergoes an open appendicectomy performed via a lanz incision. This surgeon places the incision on a level of the anterior superior iliac spine in an attempt to improve cosmesis. During the procedure the appendix is found to be retrocaecal and the incision is extended laterally. Which of the following nerves is at greatest risk of injury?
A
llioinguinal
20
Q
21- 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?
A
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 andperitoneum lie posterior to it. Bucks fascia lies in the penis.
21
Q
22- How many unpaired branches leave the abdominal aorta to supply the abdominal viscera?
A
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.
22
Q
23- 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?
A
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.
23
Q
24- 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?
A
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.
24
25-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?
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.
25
26- 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 maxim
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.
26
27- 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:
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.
27
28- 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?
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.
28
29- 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?
lleo-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.
29
30- In a patient with a carcinoma of the distal sigmoid colon, what is the most likely source of its blood supply?
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.
29
31- 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?
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.
30
32- 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?
Left renal vein
The left renal vein runs across the surface of the aorta and may require deliberate ligation during juxtarenal aneurysm repair.
31
36- 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?
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.
31
33- 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?
Inferior phrenic artery
The superior adrenal artery is a branch of the inferior phrenic artery.
31
35- 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:
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.
31
34- A 56 year old man is having a long venous line inserted via the femoral vein into the right atrium for CVP measurements. The catheter is advanced through the IVC. At which of the following levels does this vessel enter the thorax?
T8
The IVC passes through the diaphragm at T8.
32
37- Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?
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.
32
40- 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?
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.
32
38- From which embryological structure is the ureter derived?
Mesonephric duct
The ureter develops from an 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.
33
39- 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.
34
41- In a patient with an ectopic kidney where is the adrenal gland most likely to be located?
In its usual position
Because the kidney is present, rather than absent, the adrenal will usually develop and in the normal
location.
35
42- Which of the following is not a branch of the abdominal aorta?
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.
36
44- 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?
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.
36
43- A 49 year old man undergoes a low anterior resection for cancer. He is assessed in the outpatient clinic post operatively. His wounds are well healed. However, he complains of impotence. Which of the following best explains this problem?
Damage to the nervi erigentes
The penis takes autonomic nerves from the nervi erigentes that lie near the seminal vesicles. These may be compromised by direct surgical trauma (such as use of diathermy in this area) and also by radiotherapy that is used in these patients pre operatively. The result is that up to 50% of patients may develop impotence following rectal cancer surgery.
37
45- Which of these structures are not contained within the rectus sheath?
Internal iliac artery
The rectus sheath also contains:
superior epigastric vein
inferior epigastric artery
38
46- 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?
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.
39
47- From which structure is the central tendon of the diaphragm derived?
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.
40
48- A 55 year old man is admitted with a brisk haematemesis. He is taken to the endoscopy department and an upper Gl 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?
Common hepatic artery
The vessel will be the gastroduodenal artery, this arises from the common hepatic artery.
41
49- 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?
llioinguinal
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.
42
50- Which of the following vessels does not drain directly into the inferior vena cava?
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.
43
51- 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?
Transversalis fascia
The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric vessels form its inferomedial wall.
44
52- 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?
Gastroduodenal artery
The gastroduodenal artery divides into the gastro-epiploic and pancreaticoduodenal arteries at the superior aspect of the pancreas.
45
53- 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?
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)
46
55- 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?
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.
46
54- What is the lymphatic drainage of the membranous urethra?
Internal iliac nodes
The prostatic and membranous urethra drain to the internal iliac nodes.
47
57- 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?
L4
The aorta bifurcates at L4. An important landmark that is tested frequently.
47
56- Which of the following statements relating to the greater omentum is false?
It has no relationship to the lesser sac.
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.
48
58- Which of the following structures lies most posteriorly at the porta hepatis?
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.
49
59- What is the most inferior anterior aortic branch?
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.
50
60- 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?
Appendix base
The tenia coli converge at the base of the appendix.
51
61- 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?
Portal vein
The portal vein, hepatic artery and common bile duct are occluded.
52
63- 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?
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.
52
62- A 56 year old lady undergoes a Hartmann's style resection of the sigmoid colon, with ligation of the vessels close to the colon. Which of the following vessels will be responsible to supplying the rectal stump directly?
Superior rectal artery
This question is addressing the blood supply to the rectum. Which is supplied by the superior rectal artery. High ligation of the IMA may compromise this structure. However, the question states that during the Hartmans procedure the vessels were ligated close to the bowel. Implying that the superior rectal was preserved.
53
66- Which of the following aortic branches leaves the aorta approximately 1cm below the coeliac axis?
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.
53
64- 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?
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.
53
65- 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:
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.
54
67- Which of the following structures is not directly related to the right adrenal gland?
Right renal vein
The right renal vein is very short and lies more inferiorly.
55
68- 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?
Transversalis fascia
Inguinal canal walls: 'MALT: 2M, 2A, 2L, 2T':
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.
56
69- At what level does the aorta bifurcate into the left and right common iliac arteries?
L4
The aorta typically bifurcates at L4. This level is usually fairly constant and is often tested in the exam.
57
70- Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following?
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.
58
71- At which of the following spinal levels does the oesophagus pass through the diaphragm into the abdominal cavity?
T10
The oesophagus passes into the abdomen at T10.
59
72- The oesophagus is constricted at the following levels apart from:
Lower oesophageal sphincter
Constrictions of the oesophagus : ABCD
A- Arch of the Aorta
B- Left main Bronchus
C- Cricoid Cartilage
D- Diaphragmatic Hiatus
The oesophagus is not constricted at the level of the lower oesophageal sphincter.
60
73- Which of the following overlies the outer muscular layer of the intrathoracic oesophagus?
Loose connective tissue
The oesophagus has no serosal covering and hence holds sutures poorly. The Auerbach's and Meissner's nerve plexuses lie in between the longitudinal and circular muscle layers and submucosally. The sub mucosal location of the Meissner's nerve plexus facilitates its sensory role.
61
74- Which of the following types of epithelium lines the lumenal surface of the normal oesophagus?
Non keratinised stratified squamous epithelium
The oesphagus is lined by non keratinised stratified squamous epithelium. Changes to glandular type epithelium occur as part of metaplastic processes in reflux.
62
75- Which of the following is true in connection with the phrenic nerves?
They both lie anterior to the hilum of the lungs
C3,4,5
Keeps the diaphragm alive!
They both lie anterior to the hilum of the lung. The phrenic nerves have both motor and sensory functions. For this reason sub diaphragmatic pathology may cause referred pain to the shoulder.
63
76- 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?
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
64
77- 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?
Abdominal aorta
The testicular artery is a branch of the abdominal aorta.
65
78- 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?
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.
66
79- Which of the following is not a branch of the hepatic artery?
Pancreatic artery
The pancreatic artery is a branch of the splenic artery.
67
80- A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum. What is the most likely explanation?
Damage to the hypogastric plexus during mobilisation of the inferior mesenteric artery
Autonomic nerve injury is the most common cause.
68
81- 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?
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.
69
82- 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?
L2
The renal arteries usually branch off the aorta on a level with L2.
70
84- 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?
lliac 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.
70
83- Through which of the following foramina does the genital branch of the genitofemoral nerve exit the abdominal cavity?
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).
71
85- Which of the following structures is not located in the superficial perineal space in females?
Pudendal nerve
The pudendal nerve is located in the deep perineal space and then branches to innervate more superficial structures.
72
86- 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?
Hind gut
The left colon is embryologically part of the hind gut. Which accounts for its separate blood supply via the IMA.
73
88- 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?
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.
73
87- 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 ?
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.
74
89- 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?
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.
75
90- 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?
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.
76
91- 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?
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).
77
92- 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?
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.
78
93- What is the lymphatic drainage of the female urethra?
Internal iliac nodes
The entire female urethra drains to the internal iliac nodes.
78
94- Which of the following pairings are incorrect?
Termination of dural sac and L4
Vena cava T8 (eight letters)
Oesophagus T10 (ten letters)
Aortic hiatus T12 (twelve letters)
It terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates at L1.
79
95- Which of the following is not a content of the porta hepatis?
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.
80
96- An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following forms the posterior wall of the femoral canal?
Pectineal ligament
80
97- 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?
Branches of the renal artery
The proximal ureter is supplied by branches from the renal artery.
81
98- 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?
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.
81
99- A 53 year old man with a carcinoma of the lower third of the oesophagus is undergoing an oesophagogastrectomy. As the surgeons mobilise the mid part of the oesophagus, where are they most likely to encounter the thoracic duct?
Posterior to the oesophagus
The thoracic duct lies posterior to the oesophagus and passes to the left at the level of the Angle of Louis. It exits the thorax at T12 together with the aorta.
81
100- A 72 year old lady is suspected of having a femoral hernia. At which of the following sites is it most likely to be identifiable clinically?
Below and lateral to the pubic tubercle
Femoral hernias exit the femoral canal below and lateral to the pubic tubercle. Femoral hernia occur mainly in women due to their difference in pelvic anatomy. They are at high risk of strangulation and therefore should be repaired.
81
101- 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?
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.
Posteriorlylnferior vena cava
Inferiorly1st part of the duodenum
SuperiorlyCaudate process of the liver
81
102- 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?
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.
82
103- 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.
83
104- 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?
llioinguinal nerve
84
105- 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.
84
106- 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.
85
108- 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
86
107- 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.
87
109- 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.
88
110- 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.
89
111-The superior aspect of the vagina drains to which of the following lymph node groups?
Internal iliac nodes
90
112- 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.
91
113- 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.
92
115- Which of the positions listed below best describes the location of the coeliac autonomic plexus?
Anterior to the aorta
92
114- 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.
93
116- 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?
llioinguinal
94
117- At which of the following levels does the inferior vena cava exit the abdominal cavity?
T8
95
118- 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
96
119- 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.
97
120- 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.
97
121- Which of the following statements relating to quadratus lumborum is false?
Causes flexion of the thoracic spine ( True)
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 quadratus lumborum does so is incorrect.
98
122- During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Azygos vein
The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.
99
123- 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.
100
124- 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.
101
125- 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.
101
126- 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.
102
127- Which of the following ligaments contains the artery supplying the head of femur in children?
Ligamentum teres
103
128- 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.
103
129- 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.
104
130- 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.
105
131- 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.
106
132- 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.
107
133- 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
108
134- 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)
109
135- 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.
110
136- Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of the following dermatomal levels will require blockade?
T12
111
137- A 75-year-old man presents with hepatomegaly and ascites. A CT scan shows evidence of post hepatic portal hypertension. The inferior vena cava passes through the diaphragm at which vertebral level?
T8
It passes through the diaphragm at T8.
112
138- Following an oesophagogastrectomy the surgeons will anastomose the oesophageal remnant to the stomach, which of the following is not part of the layers that comprise the oesophageal wall?
Serosa
The oesophageal wall lacks the serosa layer
The wall lacks a serosa which can make the wall hold sutures less securely.
113
139- 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.
113
140- 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.
114
141- 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.
115
142- 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 coccyx?
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
116
143- 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?
llioinguinal 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.
117
144- 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.
117
145- 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.
118
146- A 1 year old boy is referred because of an impalpable testis in the left scrotum. Which of the following positions describes an ectopic testis?
At the base of the penis
A testis at the base of the penis is ectopic, not listed is the superficial inguinal pouch (one of the commonest ectopic sites). A testis located at deep or superficial rings or intra canalicular is not ectopically located.
119
147- 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.
120
148- 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.
121
149- A 73 year old lady is admitted with brisk rectal bleeding. Despite attempts at resuscitation the bleeding proceeds to cause haemodynamic compromise. An upper Gl 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.
122
123
150- 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.
124
152- 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.
125
153- 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.
126
154- 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?
lleo-colic artery
The appendicular artery is a branch of the ileocolic artery.
127
155- A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of these 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.
128
156- 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.
129
157- 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 thecanal in the ischiorectal fossa.
130
158- What is the anatomical level of the transpyloric plane?
L1
131
159- 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.
132
160- 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.
132
161- 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.
133
162- Where are the reticulo-endothelial cells concentrated within the spleen?
Within the white pulp
The reticuloendothelial cells are concerned with the immune functions of the spleen and these are therefore concentrated in the white pulp.
134
163- 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.
135
164- 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
136
165- 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 wit that of cyctic 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.
137
166- A 67 year old man is undergoing a transurethral resection of a bladder tumour using diathermy. Suddenly during the procedure the patient's thigh begins to twitch. Stimulation of which of the following nerves is the most likely cause?
Obturator
The obturator nerve is most closely related to the bladder
138
167- 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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168- 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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169- 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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170- 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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171- 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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172- 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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173- 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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174- 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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175- 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-ortic nodes.
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176- Which of the following is most important in providing support to the duodenojejunal flexure?
Ligament of Treitz
The suspensory muscle of the duodenum which is referred to as the ligament of Treitz is most important. The ligament of Treves is located between the ileum and caecum.
