6- Abdomen & Pelvic MSQs Only (2) Flashcards
1- The transversalis fascia contributes to which of the following?
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- Which of the following nerves is the primary source of innervation to the anterior scrotal skin?
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- Which of the following statements relating to the gallbladder is untrue?
Cholecystokinin causes relaxation of the gallbladder
CCK causes gallbladder contraction.
4-The inferior aspect of the vagina drains to which of the following lymph node groups?
Superficial inguinal nodes
5- Which of the following options in relation to the liver is true?
-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- 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?
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- 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?
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- 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?
10cm
8 cm is still within normal limits. However, caecal diameters of 9 and 10 are pathological and should prompt further investigation.
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?
Inguinal
The scrotum is drained by the inguinal nodes.
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?
Rectus abdominis
This structure will be the rectus sheath and when entered the rectus abdominis muscle will be encountered.
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?
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- The following statements regarding the rectus abdominis muscle are true except:
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.
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?
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.
14- Where are accessory spleens not found?
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
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?
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.
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?
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.
17- Which of the following structures is not at the level of the transpyloric plane?
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.
18- A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?
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.
19- During embryological development, which of the following represent the correct origin of the pancreas?
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.
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?
llioinguinal
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?
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.
22- How many unpaired branches leave the abdominal aorta to supply the abdominal viscera?
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.
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?
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.
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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)
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.
54- What is the lymphatic drainage of the membranous urethra?
Internal iliac nodes
The prostatic and membranous urethra drain to the internal iliac nodes.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
