Abdomen and pelvis II

Question 1

From the groups of lymph nodes listed, choose to which of them the following cancers first metastasise.
Cervical carcinoma

Answer 1

Internal iliac lymph nodes
The main lymph drainage from the cervix is to the external and internal iliac nodes by lymphatic channels that run in front of and behind the ureter. Unlike the uterus there is no drainage to the inguinal nodes.

Question 2

From the groups of lymph nodes listed, choose to which of them the following cancers first metastasise.

Testicular carcinoma

Answer 2

Para-aortic nodes
The lymphatic drainage from the testes runs with the testicular artery to the para-aortic nodes at the level of origin of the testicular artery (from the anterior aorta a little below the renal arteries - L2). There is no drainage to the inguinal lymph nodes, unlike the scrotal skin.

Question 3

From the groups of lymph nodes listed, choose to which of them the following cancers first metastasise.

Distal anal carcinoma

Answer 3

Superficial inguinal lymph nodes
The lymph drainage from the distal anal canal is to the superficial inguinal lymph nodes. The proximal anal canal drains to the internal iliac nodes.

Question 4

Which of the following structures would be seen as a posterior relation of the first part of the duodenum on a CT scan?
(Please select 1 option)
	 Abdominal aorta
	 Main pancreatic duct
	 Portal vein
	 Superior mesenteric vessels
	 Transverse colon

Answer 4

Portal vein

The duodenum is often divided anatomically into four sections.

The posterior relations of the first part of the duodenum are the portal vein, common bile duct and gastroduodenal artery (inferior vena cava behind this).

The abdominal aorta crosses by the third part of the duodenum.

The superior mesenteric vessels are an anterior relation of the third part of the duodenum.

The main pancreatic duct opens into the second part of the duodenum.

The second part of the duodenum is crossed by the transverse colon.

Question 5

A 65-year-old man is undergoing surgery for a tumour of his stomach.
Before dissection can start the surgical anatomy has to be identified. You identify the communicating cavity between the greater and lesser sacs in the abdomen.
Which of the following forms the lower boundary of this area?
(Please select 1 option)
First part of duodenum
Hepatic artery
Portal vein
Quadrate lobe of the liver
Second part of the duodenum

Answer 5

1st part of duodenum

The boundary between the greater and lesser sacs is known as the epiploic foramen.

Its lower border is formed by the first part of the duodenum.

Superiorly lies the caudate lobe of the liver.

The posterior border is formed by the inferior vena cava.

The anterior border is formed by the common bile duct, hepatic artery, and portal vein.

Question 6

An obese 43-year-old lady is undergoing a laparoscopic cholecystectomy.
Access is extremely difficult, and the operation is hampered by bleeding which seems to be a result of arterial damage. The operating surgeon converts to an open procedure. The bleeding is presumed to be coming from the cystic artery.
To gain temporary haemostasis, the surgeon decides to press on the hepatic artery.
Where should he press?
(Please select 1 option)
Anterior wall of the foramen of Winslow
Caudate lobe of the liver
First part of the duodenum
Fundus of the gallbladder
Posterior wall of the foramen of Winslow

Answer 6

Anterior wall of the foramen of Winslow

Pringle’s manoeuvre is when the surgeon compresses the hepatic artery where it lies in the anterior wall of the foramen of Winslow.

The cystic artery can be damaged in gallbladder surgery.

The cystic artery is a branch of the right hepatic artery. The cystic artery must be identified during cholecystectomy; it normally lies in the triangle formed by the liver, cystic duct and common hepatic duct.

Bleeding is one of the indications for converting from a laparoscopic to an open cholecystectomy.

Question 7

Which of the following is true of the spleen?
(Please select 1 option)
Is the largest lymphoid organ in the body
Is usually palpable when normal
Lies obliquely between the seventh and tenth rib
The lower pole extends beyond the mid-axillary line
Usually measures 16 cm in maximum length when healthy

Answer 7

Largest lymphoid organ

The spleen is situated in the left hypochondrium between the gastric fundus and left hemidiaphragm.

It is usually a domed-shaped tetrahedron with its shape dictated by the impressions of the stomach, left kidney, pancreas and splenic flexure.

In the adult it is approximately 12 cm long, 7 cm broad and 4 cm wide.

The spleen lies between the ninth and eleventh rib with the long axis lying along the tenth rib. The lower pole does not extend beyond the mid-axillary line.

Enlargement of the spleen occurs along the tenth rib, with the spleen becoming palpable only when at least three times its normal size.

Question 8

Which statement is not true regarding the boundaries of the inguinal canal?
(Please select 1 option)
The anterior wall is formed laterally by the internal oblique
The deep inguinal ring is a defect in the transversalis fascia
The floor is formed laterally by the lacunar ligament
The posterior wall is formed by the conjoin tendon medially
The roof is formed by internal oblique and transversus muscles

Answer 8

The floor is formed laterally by the lacunar ligament

The inguinal canal is an oblique intermuscular passage through the anterior abdominal wall. It extends from the deep inguinal ring, a deficiency in the transversalis fascia just above the midpoint of the inguinal ligament, to the superficial ring, a deficiency in the external oblique aponeurosis, lying just above the pubic tubercle.

The canal is approximately 4 cm long.

Its anterior wall is formed by the external oblique aponeurosis, assisted laterally by a portion of the internal oblique muscle.

Its floor is the inrolled lower edge of the inguinal ligament, reinforced medially by the lacunar ligament.

Its roof is formed by the lower edges of the internal oblique and transversus muscles.

The posterior wall is formed by the conjoint tendon (combined tendons of internal oblique and transversus muscle which insert into the pubic crest and pectineal line of the pubic bone) and the weak transversalis fascia laterally.

Question 9

Which of the following is true regarding the inguinal canal?
(Please select 1 option)
Anterior wall is composed solely of the external oblique aponeurosis
Inferior wall is formed by external oblique aponeurosis
Is an oblique passage in the newborn infant
Posterior wall is formed by internal oblique
Roof is formed by the internal oblique and transversus abdominal muscles

Answer 9

Roof is formed by the internal oblique and transversus abdominal muscles This is the correct answerThis is the correct answer
The anterior wall of the inguinal canal is formed by the aponeurosis of the external oblique muscle and internal oblique muscle in its lateral third.

The floor (inferior wall) is formed by the inguinal ligament and the lacunar ligaments and the roof is formed by fibres of internal oblique and transversus abdominis.

The canal is an oblique passageway except in the newborn.

The posterior wall is composed of the fascia transversalis and the conjoint tendon.

Question 10

Which of the following is not a cause of a tender scrotal swelling in infancy?
(Please select 1 option)
	 Balanitis
	 Breech delivery
	 Epididymo-orchitis
	 Orchidoblastoma
	 Torsion of testis

Answer 10

Balanatis

All the above except balanitis are potential causes of tender scrotal swelling in infancy.

Breech delivery may produce trauma with haematoma.

Orchidoblastoma or yolk sac tumours are the commonest cause of testicular cancer in children. Usually alpha-fetoprotein (AFP) is grossly elevated.

Question 11

Which of the following is true of the great (long) saphenous vein?
(Please select 1 option)
Ascends posterior to the medial malleolus
Passes through Colles’ fascia
Passes through the femoral canal
Receives blood from the posterior tibial veins
Receives the superficial external pudendal vein

Answer 11

Receives the superficial external pudendal vein This is the correct answerThis is the correct answer
The long saphenous vein can be divided into six anatomic regions

The femoral triangle
The anterior femoral region
The patellar region
The anterolateral leg
The pasteromedial leg, and
The foot.
It has a linear course in the leg. It ascends vertically, posterior to the medial border of the tibia.

It is accompanied by the leg branch of the saphenous nerve. This anatomical relation obviously carries a risk of sensory disorders following stripping.

At the knee the long saphenous vein travels posteriorly to the medial femoral condyle (second constant anatomical landmark).

It then travels superficially over the medial region of the thigh, remaining parallel to the medial edge of the sartorius muscle.

In the femoral triangle, the long saphenous vein forms an arch as it penetrates into the depth of the thigh. It perforates the cribriform fascia immediately above Allan Burn’s ligament, which actually corresponds to a reinforcement or fold of the cribriform fascia.

The arch of the long saphenous vein then opens onto the anterior surface of the femoral vein 4 centimetres below the inguinal ligament. It enters the femoral vein at this junction which then passes through the femoral canal.

The external pudendal veins drain to the iliac veins. The long saphenous may drain into the posterior tibial veins.

The valves of the perforating veins should prevent backflow of blood from the deep to the superficial system.

In 75% of occasions the long saphenous receives blood from the superficial external pudendal veins.

Question 12

Which of the following is correct regarding the prostate gland?
(Please select 1 option)
Is an endocrine gland
Is traversed by ejaculatory ducts
Lies lateral to the levator ani muscle
Lies medial to the ureters
Receives its blood supply from the pudendal artery

Answer 12

Is traversed by ejaculatory ducts

The prostate is supplied by the inferior vesical vessels and is an exocrine gland.

The ejaculatory ducts pass through the prostate gland to empty into the urethra.

The ureters lie superiorly posterior to the gland draining into the trigone of the bladder.

Question 13

Which of the following is not correct concerning the adductor canal?
(Please select 1 option)
Begins at the apex of the femoral triangle
Is bounded by the adductor longus muscle medially
Is bounded by the sartorius muscle anteriorly
Is bounded by the vastus medialis muscle laterally
Transmits only structures found within the femoral sheath

Answer 13

Transmits only structures found within the femoral sheath This is the correct answerThis is the correct answer
The adductor canal is a narrow transfacial canal in the middle of the thigh and is approximately 15 cm in length.

The adductor canal begins about 15 cm inferior to the inguinal ligament, where the sartorius muscle crosses over the adductor longus muscle. Its boundaries include

Laterally: vastus medialis
Medially: adductor longus
Anteriorly: sartorius.
It is located deep to the middle third of the sartorius muscle. It provides an intermuscular passage through which the femoral vessels pass to reach the popliteal fossa, where they become popliteal vessels.

Question 14

In the femoral triangle, the femoral artery is which of the following?
(Please select 1 option)
Crossed by the superficial circumflex iliac vein
Lateral to the femoral nerve
Medial to the long saphenous vein
Posterior to the femoral vein at the apex of the triangle
Superficial to the femoral branch of the genito-femoral nerve

Answer 14

In the femoral triangle, the femoral artery is which of the following?
(Please select 1 option)
Crossed by the superficial circumflex iliac vein
Lateral to the femoral nerve
Medial to the long saphenous vein
Posterior to the femoral vein at the apex of the triangle
Superficial to the femoral branch of the genito-femoral nerve

Question 15

In the femoral triangle, the femoral artery is which of the following?
(Please select 1 option)
Crossed by the superficial circumflex iliac vein
Lateral to the femoral nerve
Medial to the long saphenous vein
Posterior to the femoral vein at the apex of the triangle
Superficial to the femoral branch of the genito-femoral nerve

Answer 15

At its origin is crossed by the ureter

The external iliac artery passes obliquely in the retroperitoneal space downward and lateral along the medial border of the psoas major, from the bifurcation of the common iliac to a point beneath the inguinal ligament.

At its origin it is crossed by the ovarian vessels in the female, and occasionally by the ureter. At the upper part of its course, the external iliac vein lies partly behind it, but further down, the vein lies entirely to its medial side.

The deep external pudendal artery usually arises from the femoral artery, but may arise from the medial circumflex femoral artery.

Question 16

At its origin is crossed by the ureter

The external iliac artery passes obliquely in the retroperitoneal space downward and lateral along the medial border of the psoas major, from the bifurcation of the common iliac to a point beneath the inguinal ligament.

At its origin it is crossed by the ovarian vessels in the female, and occasionally by the ureter. At the upper part of its course, the external iliac vein lies partly behind it, but further down, the vein lies entirely to its medial side.

The deep external pudendal artery usually arises from the femoral artery, but may arise from the medial circumflex femoral artery.

Answer 16

Superior gluteal nerve This is the correct answerThis is the correct answer
A number of structures emerge from the pelvis through the greater sciatic foramen into the gluteal region. They either pass above or below the piriformis muscle.

The superior gluteal nerve and vessels emerge above piriformis.

Below piriformis emerge the

Inferior gluteal nerve and vessels
Pudendal nerve and vessels
Nerve to obturator internus
Sciatic nerve
Posterior femoral cutaneous nerve
Nerve to quadratus femoris.

Question 17

Which of the following statements is correct regarding both the ureters in the female?
(Please select 1 option)
Cross above the uterine arteries to enter the bladder
Cross near the bifurcation of the external iliac artery
Have three sites of anatomical constriction
Pass anterior to the ovarian vessels
Run on the lateral surface of the psoas major muscle

Answer 17

Have three sites of anatomical constriction

Both ureters run distally on the anterior surface of the psoas major muscle and cross medially near the bifurcation of the common iliac artery. They run posterior to the ovarian vessels.

There are three sites of anatomic constriction

Pelvo-ureteric conjunction
Where the ureter crosses the pelvic brim
Vesico-ureteric junction.
The ureters cross below the uterine arteries near the cervix.

Question 18

In the thigh, which of the following is correct?
(Please select 1 option)
Both the great saphenous vein and the femoral artery pass through the adductor canal
Rectus femoris forms the lateral boundary of the femoral triangle
The femoral nerve enters the thigh within the femoral sheath
The ilioinguinal nerve innervates skin over its medial aspect
The lacunar ligament is the medial border of the femoral ring

Answer 18

The lacunar ligament is the medial border of the femoral ring This is the correct answerThis is the correct answer
The lateral border of the femoral triangle is formed by

The medial surface of sartorius
The inguinal ligament
The superior border
The medial border by adductor longus.
The femoral nerve lies outside the femoral sheath which includes the vessels.

The medial thigh is supplied by the cutaneous branches of the femoral nerve which also supplies the muscles of the anterior compartment of the thigh, including the pectineus muscle.

The psoas muscle receives its nerve supply from the lumbar plexus.

The saphenous nerve together with the femoral artery pass through the adductor canal.

The abdominal opening of the femoral canal is the femoral ring. Its boundaries include:

Anteriorly, the inguinal ligament
Medially, the lacunar ligament
Posteriorly, the pectineal ligament, and:
Laterally, the femoral vein.

Question 19

Which of the following is true of the pleura?
(Please select 1 option)
Does not extend into the pulmonary interlobular fissures
Extends superiorly to the level of the second rib
Is only in contact with the visceral structures
Lies posterior to the upper pole of the right kidney
Over the diaphragm is supplied by the coeliac plexus

Answer 19

Lies posterior to the upper pole of the right kidney

There are two pleurae - parietal and visceral - in contact with the chest wall and lungs respectively.

Mediastinal pleura is the portion of the parietal pleural membrane that lines the mediastinum. It is bounded by and is continuous with the anterior and posterior margins of the costal pleura, the cervical pleura superiorly and the diaphragmatic pleura inferiorly.

At the root of the lung on both sides the mediastinal parietal pleura passes laterally along the structures of the root to merge with the visceral pleura. This region is the isthmus.

Superiorly to the lung root the mediastinal pleura is a broad, uninterrupted sheet between sternum and vertebrae.

Inferior to the lung root, the mediastinal pleura is continuous with the pulmonary ligament.

Question 20

Which of the following is correct of the vermiform appendix?
(Please select 1 option)
Averages 5 cm in length
Circular muscle layer is a continuation of the taeniae coli
Embrologically elongates as rapidly as the rest of the colon
Is supplied by branches of the superior mesenteric artery
Tip is at a constant location

Answer 20

Is supplied by branches of the superior mesenteric artery

The appendix forms a wormlike (vermiform) structure as it does not elongate as rapidly as the rest of the colon.

The average length is 9 cm (range from 2-20 cm).

The wall of the appendix consists of two layers of muscle, an inner circular and outer longitudinal. The longitudinal layer is a continuation of the taeniae coli.

The appendix is lined by colonic epithelium.

Few submucosal lymphoid follicles are noted at birth. These follicles enlarge, peak from 12-20 years, and then decrease. This pattern correlates with the incidence of appendicitis.

The blood supply to the appendix is mainly from the appendicular artery, a branch of the ileocolic artery from the superior mesenteric artery. This artery courses through the mesoappendix posterior to the terminal ileum.

The base of the appendix is fairly constant and is located at the posteromedial wall of the caecum about 2.5 cm below the ileocaecal valve. This is also where the taeniae converge.

The base is at a constant location, whereas the position of the tip of the appendix varies.

In 65% of patients, the tip is located in a retrocaecal position
In 30% it is located at the brim or in the true pelvis
It is subcaecal in 2% and
Behind or in front of the terminal ileum in 3%.
The location of the tip of the appendix determines early signs and symptoms.

Question 21

Which of the following cutaneous areas and sensory roots are correctly paired?
(Please select 1 option)
	 The groin - L5
	 The index finger - C5
	 The little finger - T1
	 The sole of the foot - S3
	 The umbilicus - T10

Answer 21

The umbilicus - T10 This is the correct answerThis is the correct answer
It is better to remember key facts with dermatomes and then deduce the rest!

The patient is always standing with palms of the hands facing forwards:

C1 gives no supply to the skin, the occiput is supplied by C2
C5 supplies the outer aspect of the shoulder
C7 (the longest cervical spinous process) supplies the middle finger (the longest finger) and C8 the little finger.
T3 lies in the axilla
T8/T10/T12 supply the rib margins, umbilicus and pubis respectively
L3 supplies the knee
L5 runs diagonally from the outer aspect of the tibia to the inner aspect of the foot
Stand on S1
L5 supplies the first toe, S1 supplies the little toe
S3/4/5 are concentric rings around the anus.

Question 22

Which one of the following embryological statements is correct?
(Please select 1 option)
If the urorectal septum fails to develop, a fistula may occur between the rectum and bladder
The ascending colon is derived from the hindgut
The cloaca only gives rise to the bladder
The foregut gives rise to the duodenum and jejunum
The glomerulus is derived from the mesonephron

Answer 22

The foregut gives rise to the

Larynx
Pharynx
Oesophagus
Stomach
Duodenum.
The midgut gives rise to the duodenum and gut through to the proximal two-thirds of the transverse colon.

The hindgut gives rise to the distal third of the colon, rectum and upper anal canal.

The kidney is derived from the metanephros (glomeruli, proximal and distal tubules).

The lower part of the mesonephric (Wolffian) duct gives rise to the ureteric bud, which will constitute the collecting system.

Question 23

A 24 year old man falls and lands astride a manhole cover. He suffers from a injury to the anterior bulbar urethra. Where will the extravasated urine tend to collect?

	A.	Lesser pelvis
	B.	Connective tissue of the scrotum
	C.	Deep perineal space
	D.	Ischiorectal fossa
	E.	Posterior abdominal wall

Answer 23

Connective tissue of scrotum

This portion of the urethra is contained between the perineal membrane an the membranous layer of the superficial fascia. As these are densely adherent to the ischiopubic rami, extravasated urine cannot pass posteriorly because the 2 layers are continuous around the superficial transverse perineal muscles.

Question 24

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?

	A.	T10
	B.	L2
	C.	L3
	D.	T8
	E.	T12

Answer 24

Coeliac trunk branches:

Left Hand Side (LHS)

Left gastric
Hepatic
Splenic

The coeliac axis branches off the aorta at T12.

The coeliac axis has three main branches.
Left gastric
Hepatic: branches-Right Gastric, Gastroduodenal, Right Gastroepiploic, Superior Pancreaticoduodenal, Cystic.
Splenic: branches- Pancreatic, Short Gastric, Left Gastroepiploic

It occasionally gives off one of the inferior phrenic arteries.

Relations
Anteriorly Lesser omentum
Right Right coeliac ganglion and caudate process of liver
Left Left coeliac ganglion and gastric cardia
Inferiorly Upper border of pancreas and renal vein

Question 25

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?

A.	Division of the coronary ligaments of the liver
B.	Mobilisation of the colonic hepatic flexure
C.	Division of the right renal vein
D.	Division of the ligament of Trietz
E.	Division of the right colic artery

Answer 25

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

Question 26

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?

	A.	Hepatic artery
	B.	Cystic duct
	C.	Greater omentum
	D.	Superior mesenteric artery
	E.	Inferior vena cava

Answer 26

IVC

Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the epiploic foramen.

The epiploic foramen has the following boundaries:
Anteriorly (in the free edge of the lesser omentum): Bile duct to the right, portal vein behind and hepatic artery to the left.
PosteriorlyInferior vena cava
Inferiorly1st part of the duodenum
SuperiorlyCaudate process of the liver

Question 27

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?

A.	Mid inguinal point
B.	Above and medial to the pubic tubercle
C.	Below and lateral to the pubic tubercle
D.	Mid point of the inguinal ligament
E.	3 cm superomedially to the superficial inguinal ring

Answer 27

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.

Question 28

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?

	A.	Right colic artery
	B.	Inferior vena cava
	C.	Aorta
	D.	External iliac artery
	E.	Gonadal vessels

Answer 28

The gonadal vessels and ureter are important posterior relations that are at risk during a right hemicolectomy.

Question 29

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?

	A.	Branches of the renal artery
	B.	External iliac artery
	C.	Internal iliac artery
	D.	Direct branches from the aorta
	E.	Common iliac artery

Answer 29

Branches of renal artery

The proximal ureter is supplied by branches from the renal artery. For the other feeding vessels - see below.

Ureter

25-35 cm long
Muscular tube lined by transitional epithelium
Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses the bony pelvis
Retroperitoneal structure overlying transverse processes L2-L5
Lies anterior to bifurcation of iliac vessels
Blood supply is segmental; renal artery, aortic branches, gonadal branches, common iliac and internal iliac
Lies beneath the uterine artery