Abdomen and Pelvis IV Flashcards

1
Q

In the femoral triangle, which of the following is true of the femoral artery?
(Please select 1 option)
Crossed by the external pudendal vein
Lateral to the femoral nerve
Medial to the long saphenous vein
Posterior to the femoral branch of the genitofemoral nerve
Posterior to the femoral vein at the apex of the triangle

A

Posterior to the femoral branch of the genitofemoral nerve

The femoral triangle is the name given to an area of the anterior aspect of the thigh formed as different muscles and ligaments cross each other producing an inverted triangular shape.

Looking at the triangle from above:

The medial border of the sartorius forms the lateral border of the triangle
The inguinal ligament forms the superior border, and
The medial border of the adductor longus forms its medial border.
The apex is produced when the medial border of the sartorius crosses the medial border of the adductor longus.

The floor of the femoral triangle is muscular and roughly concave or gutter shaped, formed from medial to lateral by:

The adductor longus
Part of the adductor brevis
The pectineus, and
The iliopsoas.
Contained within this area, placed medially to laterally, are the femoral vein, artery, and nerve (easily remembered by using the mnemonic 'van').

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

The genitofemoral nerve divides into two branches as it emerges from the anterior surface of the psoas major. The femoral branch supplies the skin of the upper part of the femoral triangle whereas the genital branch passes through the inguinal canal alongside the spermatic cord, and supplies the scrotal skin and cremasteric muscle. In the female it supplies the skin of the mons pubis and labia majora.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q
Which of the following nerve roots, if compressed by a herniated disc, would result in a diminished knee jerk?
(Please select 1 option)
	 L4
	 L5
	 S1
	 S2
	 S3
A

L4

L3/L4 nerve root compression results in a diminished knee jerk.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q
Which of the following muscular tendons does not make up the rotator cuff in the shoulder?
(Please select 1 option)
	 Infraspinatus
	 Latissimus dorsi
	 Subscapularis
	 Supraspinatus
	 Teres minor
A

Latissimus dorsi

The rotator cuff is an important structure in the shoulder joint which helps in stabilising the humeral head within the glenoid, particularly when the arm is flexed or abducted by the deltoid muscle.

It is formed by a sheath of conjoint tendons which run over the top of the shoulder capsule and insert into the greater tuberosity of the humerus.

The tendons which make up the rotator cuff of the shoulder are

Supraspinatus
Infraspinatus
Teres minor
Subscapularis.
Supraspinatus inserts into the tip of the greater tuberosity of the humerus. It is responsible for initiating abduction of the arm.

Infraspinatus inserts just behind and below the tip of the tuberosity. It helps in external rotation of the arm.

Teres minor is completely hidden beneath the deltoid, as it passes behind the origin of the triceps to get inserted at the greater tuberosity of the humerus.

Subscapularis is the only rotator cuff muscle that gets inserted into the lesser tuberosity of the humerus.

Latissimus dorsi and coracobracilis do not play any part in the formation of the rotator cuff.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Which of the following is true in the ischiorectal fossa?
(Please select 1 option)
The inferior haemorrhoidal veins cross transversely
The levator ani muscle forms the floor of the fossa
The obturator internus muscle lies in its medial wall
The perianal fascia separates it from the perianal space
The pudendal nerve lies within the fat of the fossa

A

The perianal fascia separates it from the perianal space

The ischiorectal fossa has its base directed to the surface of the perineum and its apex at the line of meeting of the obturator and anal fascia. The levator ani muscle forms the inner wall and roof of the ischiorectal fossa.

It is bounded

Medially by the sphincter ani externus and the anal fascia
Laterally by the tuberosity of the ischium and the obturator fascia
Anteriorly by the fascia of Colles covering the transversus perinei superficialis, and by the inferior fascia of the urogenital diaphragm
Posteriorly by the gluteus maximus and the sacrotuberous ligament.
Crossing the space transversely are the inferior haemorrhoidal vessels and nerves; at the back part are the perineal and perforating cutaneous branches of the pudendal plexus; while from the forepart the posterior labial vessels and nerves emerge.

The internal pudendal vessels and pudendal nerve lie in Alcock’s canal on the lateral wall.

The fossa is filled with fatty tissue, across which numerous fibrous bands extend from the sides. The obturator internus forms the lateral wall of the fossa.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Which one of the following statements is untrue of the anterior abdominal wall?
(Please select 1 option)
Above the arcuate line, the transversus abdominis aponeurosis reaches the linea alba by passing posterior to the rectus abdominis muscle
Below the arcuate line, the posterior surface of the rectus abdominis muscle is in direct contact with the transversalis fascia
The inferior attachment of the rectus abdominis muscle is to the anterior aspect of the pubic symphysis and to the pubic crest
The superior and inferior epigastric vessels are contained within the rectus sheath
The transversalis fascia is the aponeurosis of transversus abdominis muscle

A

The transversalis fascia is the aponeurosis of transversus abdominis muscle This is the correct answerThis is the correct answer
The anterior abdominal wall is comprised of four muscles on each side of the midline: three of these are arranged in layers in the lateral part of the abdominal wall

External oblique (most superficial)
Internal oblique (deep to external oblique) and
Transversus abdominis (deepest layer).
As these muscles traverse medially, the fleshy part gives way to an aponeurosis which forms a sheath (rectus sheath) around the fourth muscle - the rectus abdominis. The rectus abdominis runs vertically on each side of the linea alba from the pubis (anterior aspect of the pubic symphysis and the pubic crest) to the front of the chest wall.

A complete fascial sheet lying deep to the abdominal wall muscles surrounding the peritoneal cavity is called the transversalis fascia.

The composition of the rectus sheath varies at different levels. The posterior wall of the rectus sheath thins out abruptly a short distance below the umbilicus to form the arcuate line.

Above the arcuate line, the posterior wall of the sheath comprises the transversus abdominis aponeurosis and the posterior layer of the internal oblique aponeurosis.

Below the arcuate line, all three aponeuroses pass anterior to the rectus and thus at this level the posterior surface of the rectus muscle is in direct contact with the transversalis fascia.

In addition to the rectus abdominis, the rectus sheath contains the small pyramidalis muscle, the superior and inferior epigastric vessels, and the terminal parts of the lower six intercostal nerves.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Indications for circumcision include which of the following?
(Please select 1 option)
Enuresis
Non-retractile prepuce in a 3-month-old baby
Phimosis
Scrotal thrush
Severe ammonia dermatitis

A

Phimosis

The one absolute indication for circumcision is scarring of the opening of the foreskin making it non-retractable (pathological phimosis). This is unusual before the age of 5.

Recurrent troublesome episodes of infection beneath the foreskin (balanoposthitis) are an occasional indication for circumcision.

Occasionally paediatric circumcisions are required for rare conditions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Which of the following is correct of the pancreas?
(Please select 1 option)
Derives part of its blood supply from the inferior mesenteric artery
Has the splenic and superior mesenteric veins lying behind the gland
Is pierced by the middle colic artery
Lies anterior to the right kidney
Lies in the infracolic compartments

A

Has the splenic and superior mesenteric veins lying behind the gland

The tail of the pancreas crosses the left kidney as it passes to the hilum of the spleen.

The blood supply is from the splenic, superior and inferior pancreaticoduodenal arteries.

The gland is pierced by the superior mesenteric artery.

The middle colic arises from the lower border.

It has parts in both the supracolic and infracolic compartments.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Which of the following is untrue of the micro-circulation?
(Please select 1 option)
Arterioles have no muscle
Capillaries have no innervation
Capillaries have walls made up of a single layer of cells
The capillaries contain 5% of the total blood volume at any one time
The capillaries contain gaps measuring 5-9 um wide

A

Arterioles have no muscle

Arterioles are small precapillary resistance vessels (10-50 µm) composed of an endothelium surrounded by one or more layers of smooth muscle cells.

Capillaries are small exchange vessels (6-10 µm) composed of highly attenuated endothelial cells surrounded by basement membrane with no smooth muscle.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

The rectus sheath and its contents have which one of the following characteristics?
(Please select 1 option)
Each rectus abdominis muscle is attached by a single tendon to the pubic bone
Inferior to the arcuate line the posterior layer of the rectus sheath is formed by the transversalis fascia
The external oblique aponeurosis contributes to the posterior wall of the sheath
The inferior epigastric artery is a branch of the femoral artery
The superior epigastric artery is a branch of the internal iliac artery

A

Inferior to the arcuate line the posterior layer of the rectus sheath is formed by the transversalis fascia

The rectus sheath is the fibrous condensation of the aponeurotic layers on the anterior aspect of the abdominal wall investing the two rectus abdominis muscles.

Also it encloses the epigastric vessels, the inferior five intercostal and subcostal vessels and nerves, and occasionally pyramidalis.

It is incomplete posteriorly at a level inferior to the arcuate line and superiorly above the costal margin.

The anterior wall is formed from the external oblique aponeurosis and a superficial layer of the internal oblique aponeurosis where it divides at the lateral edge of the rectus abdominis muscle.

The posterior wall is formed from the aponeurosis of the transversus abdominis muscle where it joins the deeper layer of the internal oblique aponeurosis.

Together, both walls form the linea alba.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

With regard to the abdominal vasculature, which of the following is correct?
(Please select 1 option)
The inferior pancreaticoduodenal artery arises from the inferior mesenteric artery
The left gastro-epiploic artery arises from the gastroduodenal artery
The right gastric artery rises from the hepatic artery
The right gastro-epiploic artery arises from the splenic artery
The superior rectal artery arises from the internal iliac artery

A

The right gastric artery rises from the hepatic artery

The ventral branches of the aorta include the coeliac artery and superior and inferior mesenteric arteries.

These ventral branches give rise to:

  1. Left gastric artery branches with the aortic oesophageal branches around the lower oesophagus.
  2. Anterior and posterior superior pancreaticoduodenal arteries (coeliac trunk) with the inferior pancreaticoduodenal (superior mesenteric branch) around the head of the pancreas and second part of the duodenum.
  3. The marginal artery anastomosis between the middle colic and the left colic.
  4. The superior rectal artery (inferior mesenteric) with the middle rectal (internal iliac) and/or the inferior rectal (internal pudendal from internal iliac).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Concerning the abdominal aorta, which of the following is correct?
(Please select 1 option)
Aneurysms usually arise above the origin of the renal arteries
Divides into the two common iliac arteries in front of L4
Gives off five lumbar arteries on each side
Is closely related to the right sympathetic trunk
Pierces the diaphragm in front of the T10 vertebra

A

Divides into the two common iliac arteries in front of L4

The aorta pierces the diaphragm at T12. It ends by dividing at the L4 level.

The branches are as follows:

Three unpaired anterior branches:

Coeliac
Superior mesenteric
Inferior mesenteric
Three lateral paired visceral branches:

Adrenal
Renal
Gonadal
Five lateral unpaired parietal branches:

Inferior phrenic
Four pairs of lumbar arteries.
Its terminal branches are the common iliacs and the median sacral artery.

The left sympathetic trunk is overlapped by the aorta and the right sympathetic trunk by the inferior vena cava.

More than 95% of AAAs arise below the level of the renal arteries.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Which of the following is correct concerning the umbilical artery?
(Please select 1 option)
Is a branch of the external iliac artery
Is normally a single structure
Passes through the liver
Returns deoxygenated blood to the placenta in utero
When catheterised may result in leg ischaemia

A

Returns deoxygenated blood to the placenta in utero

The umbilical artery is a bilateral structure and is a branch of the anterior division of the internal iliac artery.

It ascends out of the pelvis along the anterior abdominal wall and joins the umbilicus.

In utero, the umbilical arteries carry deoxygenated blood from the fetus to the placenta.

The inferior gluteal artery is another branch of the anterior division of the internal iliac artery and it supplies blood to the skin over the buttocks. Umbilical artery cannulation may interfere with this supply and lead to ischaemia of this area.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which of the following is correct regarding the epiploic foramen?
(Please select 1 option)
Is bounded anteriorly by the second part of the duodenum
Is bounded inferiorly by the inferior vena cava
Is bounded posterioly by the lesser omentum
Is bounded superiorly by the left lobe of the liver
Opens to the left of the aorta

A

Is bounded superiorly by the left lobe of the liver

The epiploic foramen is the entrance to the lesser sac (also known as the omental bursa as it provides a slippery surface for the posterior wall of the stomach).

The lesser sac is a diverticulum of the main peritoneal cavity.

The epiploic foramen is directed to the right and is bounded by the free edge of the lesser omentum anteriorly, the inferior vena cava posteriorly, the liver superiorly and the duodenum inferiorly.

The epiploic foramen opens to the right of the aorta.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

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

	A.	Right renal vein
	B.	Inferior vena cava
	C.	Common iliac vein
	D.	Internal iliac vein
	E.	External iliac vein
A

IVC

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

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?

	A.	Posterior
	B.	Apex
	C.	Anterior
	D.	Base
	E.	Superior aspect of the lateral side
A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

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?

	A.	Processus vaginalis
	B.	Cremaster
	C.	Mesorchium
	D.	Inguinal canal
	E.	Gubernaculum
A

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.

17
Q

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

	A.	Round ligament
	B.	Broad ligament
	C.	Uterosacral ligaments
	D.	Cardinal ligaments
	E.	Central perineal tendon
A

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.

18
Q

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?

	A.	Bulbar urethra
	B.	Membranous urethra
	C.	Internal sphincter
	D.	Prostatic urethra
	E.	Bladder neck
A

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.

19
Q

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?

	A.	Inferior epigastric artery
	B.	Conjoint tendon
	C.	Rectus abdominis muscle
	D.	External oblique aponeurosis
	E.	Transversalis fascia
A

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.

20
Q

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?

	A.	Cystic artery
	B.	Hepatic artery
	C.	Portal vein
	D.	Left gastric artery
	E.	None of the above
A

Hepatic artery
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.

21
Q

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?

	A.	Vitello-intestinal duct
	B.	Uranchus
	C.	Foregut
	D.	Hindgut
	E.	Midgut
A

Hindgut
The appendix is derived from the midgut

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

22
Q

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

A.	Mid point of the inguinal ligament
B.	Mid inguinal point
C.	2cm inferomedially to the pubic tubercle
D.	2cm superomedially to the pubic tubercle
E.	3cm inferolaterally to the deep inguinal ring
A

The mid inguinal point in the surface marking for the femoral artery.

23
Q

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?

	A.	Transversalis fascia
	B.	External oblique aponeurosis
	C.	Conjoint tendon
	D.	Rectus abdominis
	E.	Inferior epigastric artery
A

External oblique muscle
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.

24
Q

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 affected at this level?

	A.	Inferior mesenteric artery
	B.	Superior mesenteric artery
	C.	Coeliac axis
	D.	Testicular artery
	E.	None of the above
A

SMA
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.

25
Q

What is the anatomical level of the transpyloric plane?

	A.	T11
	B.	T12
	C.	L1
	D.	L4
	E.	T10
A

L1
Transpyloric plane
Level of the body of L1

Pylorus stomach
Left kidney hilum (L1- left one!)
Right hilum of the kidney (1.5cm lower than the left)
Fundus of the gallbladder
Neck of pancreas
Duodenojejunal flexure
Superior mesenteric artery
Portal vein
Left and right colic flexure
Root of the transverse mesocolon
2nd part of the duodenum
Upper part of conus medullaris
Spleen
26
Q

A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of the following structures will need to be divided to gain access to the coeliac axis?

	A.	Lesser omentum
	B.	Greater omentum
	C.	Falciform ligament
	D.	Median arcuate ligament
	E.	Gastrosplenic ligament
A

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.

27
Q

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?

	A.	Inferior mesenteric artery
	B.	Superior mesenteric artery
	C.	Ileo-colic artery
	D.	Internal iliac artery
	E.	None of the above
A

The appendicular artery is a branch of the ileocolic artery.

28
Q

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?

	A.	Portal vein
	B.	Short gastric arteries
	C.	Superior mesenteric artery
	D.	Gastroduodenal artery
	E.	None of the above
A

gastrodudenal 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.

29
Q

Which of the following nerves passes through the greater and lesser sciatic foramina?

	A.	Pudendal nerve
	B.	Sciatic nerve
	C.	Superior gluteal nerve
	D.	Inferior gluteal nerve
	E.	Posterior cutaneous nerve of the thigh
A
Pudendal nerve
Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus

Theme from 2010 Exam
Theme from January 2013 Exam
The pudendal nerve originates from the ventral rami of the second, third, and fourth sacral nerves (S2, S3, S4).

It passes between the piriformis and coccygeus muscles and exits the pelvis through the the greater sciatic foramen. It crosses the spine of the ischium and reenters the pelvis through the lesser sciatic foramen. It passes through the pudendal canal.

The pudendal nerve gives off the inferior rectal nerves. It terminates into 2 branches: perineal nerve, and the dorsal nerve of the penis or the dorsal nerve of the clitoris.

30
Q

A 43 year old man is undergoing a right hemicolectomy and the ileo-colic artery is ligated. From which of the following vessels is is derived?

	A.	Inferior mesenteric artery
	B.	Superior mesenteric artery
	C.	Coeliac axis
	D.	Aorta
	E.	None of the above
A

SMA
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.

31
Q

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?

	A.	Splenic artery
	B.	Pancreaticoduodenal artery
	C.	Gastric artery
	D.	Hepatic artery
	E.	Superior mesenteric artery
A

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.