Abdomen and Pelvis IIIa

Question 1

A 60-year-old male presents with haematemesis and undergoes an emergency gastroscopy which reveals a bleeding ulcer on the posterior wall of the stomach.

Answer 1

Splenic artery

The splenic artery passes to the spleen along the posterior wall of the lesser sac.

It also gives rise to the short gastric vessels and the left gastroepiploic artery.

Question 2

A 57-year-old lady presents with massive haematemesis and undergoes an emergency endoscopy which reveals a bleeding ulcer in the first part of the duodenum.

Answer 2

Gastroduodenal artery

The gastroduodenal artery is a branch of the hepatic artery which passed behind the first part of the duodenum where it may be eroded by a duodenal ulcer.

Question 3

Testis

Answer 3

Para-aortic

The testicular lymphatics pass with the arteries to the para-aortic nodes in the region of the renal arteries.

Question 4

Upper third of the rectum

Answer 4

Inferior mesenteric
The lymphatic drainage to the upper two thirds of the rectum is to the inferior mesenteric nodes, whilst the lower rectum drains to the internal iliac nodes.

Question 5

Vulva

Answer 5

Superficial inguinal

Lymph from the vulva, scrotum and lower limb passes to the superficial and then on to the deep inguinal nodes.

Question 6

Scrotum

Answer 6

Superficial inguinal

Question 7

Hallux

Answer 7

Superficial inguinal

Question 8

Cervix

Answer 8

Internal iliac
Most of the lymph from the cervix passes to the iliac nodes. However, some will pass in vessels along the round ligament to the superficial inguinal nodes.

Question 9

Upper anal canal

Answer 9

Inferior mesenteric

Question 10

Which of the following is true regarding the femoral artery?
(Please select 1 option)
Is a branch of the internal iliac artery
Is crossed anteriorly by the medial cutaneous nerve of the thigh
Lies lateral to iliopsoas
Lies medial to the femoral vein
Lies medial to the lymphatic vessels

Answer 10

Is crossed anteriorly by the medial cutaneous nerve of the thigh

The femoral triangle contains from medial to lateral, the femoral vein, artery and nerve.

The triangle is formed

Laterally by sartorius
The inguinal ligament superiorly and
The adductor longus medially.
The roof of the triangle are the superficial structures, namely

The fascia lata
Cribiform fascia
Subcutaneous tissue 
The skin.
The floor is muscular and is formed, from medial to lateral, by

The adductor longus
Part of the adductor brevis
The pectineus 
The iliopsoas.
The femoral vessels are enclosed in the femoral sheath with the femoral nerve lying outside the sheath.

Medial to the femoral vein within the sheath is the femoral canal, an area of dead space into which the vein can expand during increased venous return.

The femoral artery is a continuation of the external iliac artery. It exits in the triangle via the apex and enters the subsartorial (Hunter’s) canal.

The femoral artery lies at the midinguinal point, which is midway between the pubic symphysis and anterior superior iliac spine.

Question 11

In the axilla, which of the following is correct?
(Please select 1 option)
If the thoracodorsal nerve is divided in an axillary dissection the patient will have winging of the scapula
Level 3 lymph nodes are lateral to the pectoralis minor
The cords of the brachial plexus surround the first part of the axillary artery
The intercostobrachial nerve is commonly divided in axillary dissection
The subscapular artery is a branch of the third part of axillary artery

Answer 11

The subscapular artery is a branch of the third part of axillary artery This is the correct answerThis is the correct answer
The subscapular artery is the largest branch of the axillary artery, coming off from the third part.

The other branches are:

The superior thoracic
Thoraco-acromial
Lateral thoracic
Anterior
Posterior circumflex humeral.
Level 1 nodes lie lateral to pectoralis minor, level 2 behind and level 3 medial to the pectoralis minor.

The intercostobrachial nerve may be divided during axillary dissection, resulting in the patient complaining of an area of paraesthesia over the medial aspect of the inner upper arm.

If the long thoracic nerve is divided, a winged scapula will result (nerve supply to serratus anterior), but if the thoracodorsal nerve is divided (nerve supply to latissimus dorsi) there will be weakness of shoulder adduction.

The cords of the brachial plexus surround the second part of the axillary artery and this is how they derive their names, that is, lateral, posterior and medial cords, due to this anatomical relationship with the artery.

Question 12

Which of the following is true of the rectum?
(Please select 1 option)
Commences at the level of the L5 vertebrae
Drains lymph to the inguinal nodes
Has a mesentery in its proximal third
Has a parasympathetic nerve supply derived from S3
Is about 30 cm in length

Answer 12

Has a parasympathetic nerve supply derived from S3

The rectum extends from the level of the third sacral vertebral body to the anorectal line.

The third sacral corresponds to the termination of a definite mesentery. It marks the point at which there is a change in the blood supply and the level at which the tinea of the sigmoid spread out to reinforce the longitudinal muscle coat. It corresponds to the site of the rectal narrowing to join the sigmoid. It marks the change in color, the capillary pattern and the rugosity of the rectal mucosa.

The rectum varies from 10-15 cm in length, while the circumference varies from 15 cm at the rectosigmoid junction, to 35 cm or more at its widest ampullary portion.

Its parasympathetic supply is derived from the hypogastric plexus of S234 origin.

Question 13

The opening into the lesser sac is bounded by which of the following?
(Please select 1 option)
	 Anteriorly by the pancreas
	 Inferiorly by the duodenum
	 Inferiorly by the jejunum
	 Posteriorly by the superior vena cava
	 Superiorly by the gall bladder

Answer 13

Inferiorly by the duodenum

The epiploic foramen is bounded

Superiorly by the caudate lobe of liver
Posteriorly by the inferior vena cava
Inferiorly by the first part of the duodenum
Anteriorly by the portal vein contained within the free edge of the peritoneum.

Question 14

Which of the following is a branch of the femoral artery?
(Please select 1 option)
	 Peroneal artery
	 The ascending genicular artery
	 The deep epigastric artery
	 The deep external pudendal artery
	 The inferior gluteal artery

Answer 14

The deep external pudendal artery

The branches are the

Descending genicular artery
Profunda femoris
Superficial and deep external pudendal artery
Superficial epigastric
Superficial circumflex iliac arteries.
The inferior gluteal artery is a branch of the internal iliac artery.

Question 15

Which of the following is correct regarding the inguinal canal?
(Please select 1 option)
Commences at the superficial ring which is a defect in the fascia transversalis IncorrectIncorrect answer selected
Extends from the deep inguinal ring downward and laterally to the superficial inguinal ring
Is approximately 7 cm long in the adult
Lies below the inguinal ligament
Transmits the ilioinguinal nerve

Answer 15

Transmits the ilioinguinal nerve This is the correct answerThis is the correct answer
The inguinal canal in the adult is approximately 4 cm long and runs downward and medially to the superficial inguinal ring.

The canal conveys the spermatic cord in men, and in women the round ligament.

Question 16

Which of the following is true regarding the cricoid cartilage?
(Please select 1 option)
A force of 4 Newtons must be applied to the cricoid cartilage to control regurgitation
It represents the narrowest part of the airway in adults
Regurgitation of gastric contents is prevented by the Sellick manoeuvre
The lower border is attached to the first tracheal ring
The upper border is attached to the hyoid bone

Answer 16

The lower border is attached to the first tracheal ring

In adults the narrowest part of the airway is at the vocal cords, and in children it is at the level of the cricoid cartilage.

The upper border of the cricoid cartilage is attached to the thyroid cartilage (not hyoid bone) and the lower border is attached to the first tracheal ring.

The application of cricoid pressure to control regurgitation (or reduce the risk of aspiration) of gastric contents during the induction of anaesthesia was described by Sellick in 1961. It does not prevent aspiration into the trachea and it cannot prevent regurgitation up the oesophagus.

To provide protection in most of the adult population, a force of 44 Newtons should be applied to the cricoid cartilage (not 4 Newtons).

Question 17

The adductor canal contains which of the following?
(Please select 1 option)
A nerve supplying the tensor fasciae latae muscle
An artery which contributes to the genicular anastomosis
The nerve to the sartorius muscle
The profunda femoris artery
The saphenous vein

Answer 17

An artery which contributes to the genicular anastomosis

The adductor canal is a gutter-shaped groove between the vastus medialis muscle and in front of the adductor muscle. The gutter is roofed by the sartorius muscle, underneath which a fascia contains the subsartorial plexus.

The canal transmits the femoral artery and vein, saphenous nerve and, in the upper part, the nerve to the vastus medialis muscle.

The tensor fasciae latae muscle is supplied by the superior gluteal nerve (L4, L5, S1), which crosses the buttock and ends in the muscle.

Question 18

Which of the following is true regarding the diaphragm?
(Please select 1 option)
On the left side is drained by the inferior vena cava and the azygos vein
Posterior fibres arise from the thoracic vertebra
Supplied by the musculophrenic branch of the internal thoracic artery
Transmits the aorta at the level of T8 vertebra
Transmits the vagal trunks through the aortic opening

Answer 18

Supplied by the musculophrenic branch of the internal thoracic artery

The diaphragm is a dome-shaped musculofibrous septum which originates from three areas:

Sternum
Inner surfaces of the cartilages and adjacent portions of the lower six ribs on both sides
The lumbar vertebrae.
It separates the thorax from the abdominal cavity and plays a crucial role in respiration.

The diaphragm is supplied by the

Right and left phrenic arteries
Intercostal arteries
Musculophrenic branches of the internal thoracic arteries.
Venous drainage from the diaphragm occurs through the inferior vena cava and azygos vein on the right and the adrenal/renal and hemiazygos veins on the left.

The diaphragm is pierced by a series of apertures which transmit vital structures between the thorax and the abdomen. The three large openings are for the inferior vena cava, oesophagus and the aorta, and there are a few smaller openings.

The aortic opening is opposite the T12 vertebra. It transmits the aorta with the azygos vein to the right and the thoracic duct leading up from the cisterna chyli between them.

The oesophageal opening enters the abdominal cavity opposite the T10 vertebra, usually an inch to the left of the midline. It transmits the oesophagus, phreno-oesophageal ligament, the vagal trunks and the oesophageal branches of the left gastric artery, with accompanying veins and lymphatics.

The inferior vena cava enters the thorax through the opening opposite the T8 vertebra just to the right of the midline.

Question 19

Which of the following is correct regarding the relations of the abdominal structures?
(Please select 1 option)
The abdominal aorta is covered by the greater omentum anteriorly
The ascending part of the duodenum lies on the right side of the abdominal aorta
The common hepatic duct lies along the free edge of the greater omentum
The portal vein is formed by the union of the superior mesenteric vein and the splenic vein
The right branch of the hepatic artery passes in front of the common hepatic duct

Answer 19

The portal vein is formed by the union of the superior mesenteric vein and the splenic vein

The abdominal aorta is covered anteriorly by the lesser omentum and stomach, behind which are the branches of the coeliac artery and the coeliac plexus.

Posteriorly the aorta is separated from the lumbar vertebrae and intervertebral fibrocartilages by the anterior longitudinal ligament and left lumbar veins.

The ascending part of the duodenum, along with the left crus of diaphragm, the left coeliac ganglion and some coils of the small intestine, lies to the left of the abdominal aorta.

The portal vein is the upward continuation of the superior mesenteric vein, which changes its name to portal after it has received the splenic vein behind the neck of the pancreas. The right and the left hepatic ducts emerge from the porta hepatis and unite to form the common hepatic duct. It lies in the free edge of the lesser omentum, in front of the right edge of the portal vein and with the hepatic artery on its left. The right branch of the hepatic artery normally passes behind the common hepatic duct.

Question 20

Which of the following is true regarding the obturator internus muscle?
(Please select 1 option)
Forms the roof of the ischiorectal fossa
Has a fascia on its pelvic surface which gives origin to the levator ani
Is innervated by the femoral nerve
Is inserted onto the lesser trochanter of the femur
Leaves the pelvis through the obturator foramen

Answer 20

Has a fascia on its pelvic surface which gives origin to the levator ani

Obturator internus is one of the muscles of the lateral pelvic wall extending into the gluteal region. It arises from the inner surface of the obturator membrane lining the obturator foramen and the neighbouring surfaces of the pubis and ischium.

From this broad surface, it narrows down as it passes posterolaterally to form a tendon that traverses the lesser sciatic foramen. Just inferior to the ischial spine it turns laterally. There is a bursa interposed between the tendon and the bone at this point. Passing laterally, it inserts into medial surface of the greater trochanter of the femur.

The roof of the ischiorectal fossa is formed by the levator ani. It is innervated by the nerve to obturator internus (L5, S1), a branch of the sciatic nerve. The obturator internus fascia gives origin to the levator ani.

Question 21

Which of the following is correct regarding the anal sphincter?
(Please select 1 option)
The deep external anal sphincter blends with puborectalis
The external anal sphincter is supplied by branches of S1
The internal anal sphincter is attached to the outer longitudinal fibres of the rectum
The internal anal sphincter is supplied by the inferior rectal nerve
The superficial external sphincter is attached to the upper sacrum

Answer 21

The deep external anal sphincter blends with puborectalis

The external sphincter is supplied by inferior rectal nerve, and the inferior hypogastric plexus supplies the internal anal sphincter. The external sphincter is attached to the longitudinal fibres of the rectum.

The superficial external sphincter is attached from the coccyx to the perineal body.

The inferior rectal branches of pudendal supply external sphincter - S4.

Question 22

Which of the following is true regarding the anal canal?
(Please select 1 option)
Develops embryologically from the proctodeum
Is approximately 8 cm long
Is separated laterally by the levator ani from the urinary bladder
Is separated posteriorly from the vagina by the perineal body
Passes anteriorly through the pelvic floor

Answer 22

Develops embryologically from the proctodeum

The anal canal is the terminal part of the alimentary tract. The anal canal develops from the ectoderm over the cloacal membrane which becomes depressed and forms a pit in the proctodeum.

The anal canal is a continuation of the rectum which turns posteriorly through the pelvic floor and opens externally at the anus. It measures approximately 4 cm in length.

Posteriorly it is related to the anococcygeal body; laterally the levator ani separates it from the ischiorectal fossa. Anteriorly the perineal body separates it from the vagina in the female and from the bulb of the penis and the prostate gland in the male.

The canal is surrounded by the internal and external anal sphincter muscles.

Question 23

Which of the following is true of the femoral canal?
(Please select 1 option)
Contains the lymph node of Cloquet
Has the inguinal ligament as its posterior border
Has the lacunar ligament as its lateral border
Has the pectineal ligament as its anterior border
Lies lateral to the femoral vein

Answer 23

Contains the lymph node of Cloquet

The femoral canal is bordered

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

Question 24

Which of the following is correct of the pudendal nerve?
(Please select 1 option)
Arises from the posterior rami of S2, 3 and 4
Crosses the ischial spine on the lateral side of the internal pudendal artery
Leaves the pelvis through the lesser sciatic foramen
Supplies the levator ani
Supplies the testes

Answer 24

Supplies the levator ani

The pudendal nerve arises from the anterior rami of the second to fourth sacral roots. These form a trunk before leaving the pelvis via the greater sciatic foramen.

It passes immediately behind the ischial spine and swings forward to enter the perineum via the lesser sciatic foramen.

The nerve passes through the ischiorectal fossa where it gives off its terminal branches.

The inferior rectal nerve innervates the external anal sphincter and the perianal skin.

The perineal nerve innervates the sphincter urethrae and other muscles of the anterior compartment via a deep branch, and the skin of the perineum posterior to the clitoris via its superficial branch.

The dorsal nerve of the clitoris supplies the skin surrounding this structure. It supplies levator ani.