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SE book revision > Abdominal anatomy > Flashcards

Abdominal anatomy Flashcards

1
Q

At what vertebral level does the abdominal aorta bifurcate?

A

L4 lower border

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2
Q

Name the anterior unpaired branches of the abdominal aorta

A

Coeliac trunk (Lower border T12)
SMA (L1)
IMA (L3)

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3
Q

At what vertebral level does the coeliac trunk arise?

A

T12 lower border/Upper border L1

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4
Q

Which visceral organs do the branches of the coeliac trunk supply?

A

Supplies the foregut. Abdominal oeshagus, liver, gallbladder, spleen, stomach, proximal duodenum (up to second part), part of the pancreas

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5
Q

Name the major branches of the coeliac trunk

A

Left gastric artery
Common hepatic artery
Splenic artery

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6
Q

At what vertebral level does the SMA arise?

A

Lower border L1

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7
Q

Name the branches of the SMA

A

-Inferior pancreaticoduodenal artery (anterior and posterior)
-Intestinal (jejunal and ileal branches
-Middle colic
-Right colic
-Ileocolic

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8
Q

Which structures are supplied by the branches of the superior mesenteric artery?

A

Midgut
-Distal to 2nd part duodenum
-DJ flexure
-Head of pancreas
-Jejunum
-Ileum
-Caecum
-Appendix
-Axcending colon
-2/3rd transverse colon

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9
Q

At what vertebral level does the IMA arise?

A

L3 lower border

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10
Q

Name the major branches of the inferior mesenteric artery

A

-Left colic
-SIgmoidal
-Superior rectal

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11
Q

Which structures are supplied by branches of the IMA?

A

Hindgut
-distal 1/3rd of transverse colon, descending and sigmoid colon, superior rectum

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12
Q

At what vertebral level do the paried renal arteries arise?

A

L1-2

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13
Q

Name the paired arteries of the abdominal aorta

A

-Inferior phrenic (T12)
-Middle suprarenal (T12)
-Lumbar arteries (L1-L4)
-Renal arteries (L1-2)
-Gonadal arteries (L2)

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14
Q

What is an arterial aneurysm?

A

-A localised abnormal dilatation of an artery to >1.5x its normal size.
-True aneurysm involves all 3 layers of the vessel

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15
Q

Howe do you define a true and a false aneurysm

A

-True aneurysm involves all 3 layers of the vessel
-False aneurysm is characterised by breachg in vessel wall, blood is contained by adventitia. Direct communication exists between vessel lumen and aneurysm, resulting in higher risk of rupture

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16
Q

What are the indications for elective repair of an abdominal aortic aneurysm?

A

-Size >5.5cm if asymptomatic
->4.5 if increased by more than 0.5cm in last 6 months
-Symptomatic aneurysms <4.5cm should be followed up with USS every 6 months, aneurysms 4.5-5.5cm should be followed up every 3-6 months

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17
Q

Describe how abdominal aortic aneurysms can be anatomically classified?

A

-Suprarenal
-Juxtarenal
-Infrarenal

Can also be classified according to shape (saccular or fusiform)

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18
Q

What are the common interventional options for AAA?

A

-Open repair
-EVAR

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19
Q

Describe the blood supply to the liver

A

Liver receives blood from two sources: Portal vein (80%) and hepatic artery (20-30%)
–> Hepatic artery provides oxygenated blood from aorta
–> Portal venous blood is oxygen poor but nutrient rich from GI tract–> hepatic sinusoids

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20
Q

Describe the vascular segments of the liver

A

-Liver is divided into 8 segments based on branches of hepatic artery, hepatic vein and hepatic duct
-Each segment has its own branch of hepatic artery/portal vein and is drained by branch of bile duct
-Hepatic veins run between the segments and drain them
-Left lobe has segments 1-4, right lobe has segments 5-8

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21
Q

What is the function of the hepatic veins?

A

-Run between segments and drain adjacent segments.
-Drain into IVC just below diaphragm

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22
Q

Why are the vascular segments of the liver clinically significant?

A

-Lobectomy can be carried out without excessive bleeding
-Individual segments can be removed alone

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23
Q

Describe the ligaments of the liver

A

Falciform ligament
–> connects anterior liver to anterior abdominal wall
–> encloses round ligament in its free edge

Round ligament
–> remnant of umbilical vein (carries nutrient rich/oxygenated blood from placenta to the foetus
–> Joints ligamentum venosum (ductus venosus in fetus–> allows umbilical blood from placenta to bypass liver and drain directly into ivc)

Coronary ligament
–>Reflections of peritoneum onto the diaphragmatic surface of the liver
–> meet on right and left lobes to form the triangular ligaments
–> Enclose the bare area on the right side
–> has anterior and posterior layers: anterior layer is continuous with falciform ligament, posterior layer continuous with lesser omentum

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24
Q

What is the bare area of the liver?

A

-Part of the liver on right lobe not covered by peritoneum as it is in direct contact with the diaphragm
-Enclosed by anterior and posterior layers of the coronary ligament

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25
Q

What are the porto-systemic anastamoses

A

-Communications between portal venous system and systemic venous system
-Normally these channels are not open, but they can open in portal hypertension causing engorgement of portal veins and subsequent bleeding

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26
Q

Name some anatomical sites of porto-systemic anastamosis

A

Rectal
–> Portal: superior rectal vein –> IMV
–> Systemic: Middle and inferior rectal veins

Oesophageal
-Portal: Oesophageal branches left gastric vein –> splenic vein
-Systemic: Oesophageal branches left azygous

Retroperitoneal:
–> Portal: colic veins
–> Systemic: retroperitoneal veins

Paraumbilical
–> Portal: portal veins of liver
–> Systemic: Veins of anterior abdominal wall

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27
Q

What is the management of acute oesophageal variceal bleeding?

A

-ALS protocols
-A-E, resuscitation
-Terlipressin
-Endoscopic banding
-TIPS if endoscopic banding unsuccessful
-Sengstaken blakemore tube to temporise prior to endoscopy or between failed banding and TIPS

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28
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29
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30
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31
Q
A
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32
Q

(RS) describe the surface anatomy of the liver

A

Line between 4th space midclavicular line

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33
Q

(RS) Describe the course of the portal vein

A

-Originates from confluence of SV and SMV
-Runs in free edge of lesser omentum, passes through foramen of wilmslow
-Receives tributaries from gastric veins, cystic vein
-Divides into left and right

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34
Q

Describe the borders of the inguinal canal

A

-Anterior: external oblique aponeurosis, reinforced by fibres of internal oblique lateral 1/3rd
-Posterior: Transversalis fascia, conjoint tendon medial 1/3rd
-Superior: arching fibres of internal oblique and transversus abdominis
-Inferior: Inguinal ligament, lacunar ligament medial 1/3rd

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35
Q

Where is the superficial ring located?

A

Defect in external oblique, superolateral to pubic tubercle. ‘Exit’ from inguinal canal

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36
Q

Where is the deep ring located?

A

-Defect in transversalis fascia
-~ 1.5-2cm above midpoint of inguinal ligament (midway between pubic tubercle and anterior superior iliac spine)
-‘Entrance’ to canal

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37
Q

What are the contents of the inguinal canal?

A

-Round ligament in females
-Spermatic cord
-Ilioinguinal nerve

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38
Q

What are the contents of the spermatic cord?

A

3 fascia
-External spermatic fascia (external oblique aponeurosis)
-Cremasteric fascia (Internal oblique aponeurosis)
-Internal spermatic fascia (Transversalis fascia)

3 nerves
-genital branch genitofemoral nerve
-Sympathetic fibres
-ilioinguinal nerve (lies outside spermatic cord)

3 arteries
-Cremastic artery
-Testicular artery
-Artery to vas deferens

3 other things
-Pampiniform plexus of veins
-Vas deferens
-Lymphatics

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39
Q

What is the difference between a direct and an indirect inguinal hernia?

A

-Direct: Does not enter inguinal canal, occurs as weakness within transversalis fascia. Lies above and medial to pubic tubercle
-Indirect: passes through deep ring to enter inguinal canal. Lies within inguinal region or in scrotum

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40
Q

Name the boundaries of hasselbach’s triangle

A

Lateral: inferior epigastric arteries
Medial: lateral border of rectus abdominis
Inferior: inguinal ligament

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41
Q

Describe the relationship of direct and indirect hernias in relation to hasselbach’s triangle

A

Direct hernia lies medial to inferior epigastric, protruding into hasselbach’s triangle

Indirect commences lateral to inferior epigastric artery

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42
Q

Describe where femoral hernias occur in relation to the pubic tubercle

A

Below and lateral to pubic tubercle

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43
Q

What is the femoral canal?

A

-Most medial compartment of the femoral sheath
-Femoral canal extends from femoral ring proximally to level of saphenous opening distally

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44
Q

Describe the contents of the femoral canal

A

-Fat
-Lymphatics
-Cloquet’s node

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45
Q

Describe the borders of the femoral ring

A

-Anterior: inguinal ligament
-Posterior: pectineal ligament overlying superior ramus of pubis
-Medial: lacunar ligament
-Lateral: femoral vein

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46
Q

What are the indications for repair of inguinal hernia?

A

Elective repair
-Symptomatic
-Asymptomatic to prevent complications

Emergency repair:
-Obstruction
-Strangulation
-Incarceration

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47
Q

Describe the regions of the anterior abdominal wall

A

Abdomen is divided into 9 regions by 4 lines:
-1st horizontal line: Transpyloric plane (corresponds to 9th costal cartilage/L1 vertebral body)
-Transtubercular planes (joining iliac tubercles, corresponds to lower border L4 body, upper border L5 body)
-Midclavicular planes: 2x vertical lines joining midinguinal points and middle of clavicle

-Right and left hypochondrium
-Epigastric region
-Right and left flank
-Umbilical region
-Left and right iliac fossa
-Pubic region

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48
Q

At what vertebral level does the umbilicus lie?

A

In a flat and muscular abdomen, umbilicus lies at L4 level. This can vary in a pendulous abdomen

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49
Q

At what vertebral level does the transpyloric plane lie?

A

Midway between suprasternal (jugular) notch and pubic symphysis. Usually corresponds to lower border L1

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50
Q

Name some important anatomical structures which frequently lie on the transpyloric plane

A

Right to left:

  1. Upper pole of right kidney
  2. Right and left colic flexures
  3. Fundus of the gallbladder
  4. Head of the pancreas
  5. Pylorus of the stomach
  6. 2nd part of the duodenum
  7. Formation of portal vein by joining of SMV and Splenic vein
  8. DJ flexure
  9. Origin of SMA from aorta
  10. End of spinal cord in adults
    11: hilum of spleen
    12: hilum of left kidney
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51
Q

Name the layers of abdominal wall you would go through when performing an open appendicectomy

A

Skin
Subcutaneous tissue
Camper’s fascia
Scarpa’s fascia
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Parietal peritoneum

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52
Q

Name the two vertical muscles of the anterior abdominal wall

A

The two vertical muscles of the anterior abdominal wall are both contained within the rectus sheath. They are the:
-Rectus abdominis
-Pyramidalis

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53
Q

What are the contents of the rectus sheath?

A

Rectus abdominis
Pyramidalis
Superior and inferior epigastric arteries and veins
Ventral rami of T7-T12 nerve roots
Lymphatics
Fibro-fatty connective tissue

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54
Q

Describe the arterial supply to the anterolateral abdominal wall

A

Internal thoracic
–> superior epigastric artery

External iliac
–> inferior epigastric artery
–> Deep circumflex iliac artery

Femoral artery
–>Superficial circumflex iliac
–> Superficial epigastric

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55
Q

Describe location at which spigelian hernia occurs:

A

-Also known as a lateral ventral hernia
-Herniation through the aponeurotic layer between the rectus abdominis medially and the linea semilunaris laterally
-Linea semilunaris is aponeurotic layer which corresponds with border of rectus abdominis laterally

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56
Q

Name the layers you would go through when performing a midline laparotomy

A

Skin
Subcutaneous tissue
Camper’s fascia
Scarpa’s fascia
Linea alba
Transversalis fascia
Preperitoneal fat
Parietal peritoneum

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57
Q

Describe the blood supply to the stomach

A

Blood supply is derived from coeliac trunk

Lesser curvature:
–> right gastric artery (from common hepatic artery)
–> Left gastric artery (Hepatic artery proper)

Greater curvature:
–> Left gastro-epiploic artery (from splenic artery
–> right gastro-epiploic artery (from gastroduodenal artery)

Fundus and posterior:
–> short and posterior gastric arteries (from splenic)

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58
Q

Branches of common hepatic artery

A

Common hepatic
–> gastroduodenal (then continues as hepatic artery proper)

Hepatic artery proper
–> right gastric (terminates in right and left hepatic)

Right hepatic
–> cystic

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59
Q

Name the vessels that an ulcer in the lesser curve of the stomach may erode into

A

-Right and left gastric arteries

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60
Q

What is the lesser sac?

A

-Area of peritoneal cavity situated in upper abdomen
-Lies posterior to lesser omentum, stomach and associated structures

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61
Q

Name the borders of the lesser sac

A

Anterior
-Quadrate lobe, lesser omentum, posterior stomach, Gastrocolic ligament

Superior
-Superior recess lies behind caudate lobe of the liver

Inferior:
-Inferior recess lies between layers of the greater omentum (superior part)

Posterior:
-Pancreas, left kidney, left adrenal

Right:
-Epiploic foramen (of wilmslow)

Left
-Gastrosplenic
-Lienorenal

62
Q

What is the epiploic foramen?

A

-Opening through which the lesser sac communicates with the greater sac

63
Q

Name the boundaries of the epiploic foramen

A

Anterior: Free edge of lesser omentum enclosing CBD/Hepatic artery/portal vein

Inferior: 1st part duodenum

Posterior: IVC and right crus of diaphragm

Superior: Caudate lobe of the liver

64
Q

What are the boundaries of Calot’s triangle?

A

Superior: inferior border of liver
Lateral: Cystic duct
Medial: hepatic duct

65
Q

What is pringle’s maneuver?

A

Compression of the hepatic artery and portal vein between the index finger in the epiploic foramen and the thumb anteriorly, to prevent liver haemorrhage, usually secondary to trauma

66
Q

Describe what layers you would go through when performing an open cholecystectomy

A

Skin
Subcut tissue
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Parietal peritoneum

67
Q

Why is the anatomy of the second part of the duodenum clinically significant?

A

-Main pancreatic duct and common bile duct open into the small bowel here
-Site of embryological transition between foregut and midgut

68
Q

Describe the blood supply to the duodenum

A

-Up to the second part duodenum is supplied by superior pancreaticoduodenal artery from the gastroduodenal artery
-Beyond the second part duodenum is supplied by the inferior pancreaticoduodenal artery from the SMA

69
Q

Name the artery into which an ulcer in the posterior duodenum can erode?

A

-Gastroduodenal artery-close proximity to 1st part of the duodenum

70
Q

Describe the male urethra

A

Pre-prostatic urethra
–>vertical course from bladder to prostate

Prostatic urethra
–> Widest part of urethra
–> Contains urethral crest with prostatic sinuses on both sides, seminal colliculus centrally

Membranous urethra
–>Narrowest part of urethra
–> surrounded by external urethral sphincter
–> bulbourethral glands posteriorly

Spongy urethra
–>Longest part of urethra
–>Bulbourehtral glands empty into it proximally
–> Has two expansions: intrabulbar fossa in bulb of penis, navicular fossa in glans

71
Q

Why is understanding of bladder anatomy important in suprapubic catheterisation?

A

-When empty, bladder is tetrahedral in shape, with apex anteriorly and body between apex and fundus
-Fundus meets remaining surfaces of bladder at the bladder neck
-As it fills with urine, it extends superiorly betrween rectus abdominis and peritoneum but without entering peritoneal cavity
-Therefore in normal patient suprapubic catheterisation can be performed safely extra-peritoneal
-However in pt with previojs abdominal surgery, adhesions can cause loop of bowel to lie anterior to bladder

72
Q

Describe the relations of the bladder in the male

A

Superior: peritoneum
Inferior: pubic bones, obturator internus, levator ani
Fundus: rectum
Bladder neck: prostate, with seminal vesicles posteriorly

73
Q

Describe the blood supply to the bladder

A

Branches of the anterior division internal iliac

Males:
–> superior vesical artery (superior)
–> inferior vesical (inferior)

Females:
–> superior vesical (superior
–> vaginal (inferior)

Contributions also from obturator and inferior gluteal arteries

74
Q

Describe the layers of the bladder

A

In to out:
-Mucosa (transitional cells)
-Lamina propria
-Detrusor muscle

75
Q

Where are the seminal vesicles located?

A

-Between the fundus of the bladder and the rectum, superior to the prostate

note: above the seminal vesicles is a fold of peritoneum: the rectovesical pouch

76
Q

Describe the lobes of the prostate

A

Anterior lobe: Anterior to urethra
Posterior lobe: Posterior to urethra (part palpated during DRE)
Lateral lobes: form bulk of prostate
Median lobe: between urethra and ejaculatory ducts, close to bladder neck

77
Q

Where do most prostate cancers occur?

A

Lateral lobe
Peripheral zone

78
Q

What are the zones of the prostate?

A

Peripheral zone–> lateral lobe
Central zone –> median lobe (close to ejaculatory ducts)
Transitional zone –> surrounding prostatic urethra (where BPH is most common)

79
Q

What is the most common prostatic malignancy?

A

Adenocarcinoma (75% occur in peripheral zone of the prostate)

80
Q

Describe the gleason staging system for adenocarcinoma

A

-Cancer is microscopically graded 1-5 according to differentiation (1 is well differentiated, 5 is poorly differentiated)
-Prostate cancers tend to be multifocal: therefore the most common is given a primary grade, and the next most common a secondary grade.
-If there are 3 patterns, the dominant pattern is the first number, and the second is the highest grade

81
Q

How does prostate cancer metastasise?

A

-Local invasion is perineural, following the autonomic nerves

Other sites:
–>via lymphatic channels to sacral, iliac and para-aortic nodes
–> haematological to bone (pelvis, femur, vertebra) and distant viscera: liver, lungs

82
Q

Describe the location of the umbilical peritoneal folds

A

One peritoneal fold is located in the midline: median umbilical fold
One peritoneal fold either side (medial and lateral umbilical folds)

83
Q

What is the median umbilical fold?

A

Ridge of peritoneum covering the median umbilical ligament, which is the remnant of the urachus (connected the bladder to the umbilicus in foetal life)

84
Q

What are the medial umbilical folds?

A

peritoneal coverings over the medial umbilical ligaments, which are remnants of the occluded foetal umbilical arteries

85
Q

Name the structure which lies in the lateral umbilical fold

A

Inferior epigastric vessels

86
Q

What is an intraperitoneal organ?

A

Organ almost entirely covered in visceral peritoneum

87
Q

Name the intraperitoneal organs

A

-Stomach, first and 4th parts of duodenum
-DJ flexure, jejunum, ileum
-liver, spleen, tail of pancreas
-transverse colon, sigmoid colon, upper 1/3rd of rectum

88
Q

What is the difference between a primarily and secondarily retroperitoneal organ?

A

Primarily: developed in retroperitoneum

Secondarily: Initially intraperitoneal, developed suspended by a mesentery. Became retroperitoneal when mesentery fused with peritoneum. Covered on anterior surface only by peritoneum.

89
Q

What are the retroperitoneal organs?

A

Primarily:
-Kidneys
-Adrenal glands
-IVC
-Aorta
-Oesophagus

Secondarily
-2nd and 3rd parts duodenum
-Ascending and descending colon
-Pancreas (exceept tail)
-Middle 1/3rd of rectum

90
Q

What is morrison’s pouch and why is it clinically significant?

A

-Right hepatorenal space

Boundaries
-Anteriorly: liver and gallbladder
-Posteriorly: posterior abdominal wall and kidney surrounded by Gerota’s fascia
-Inferiorly: duodenum

Clinical significance: most dependent part of the abdomen, collections can accumulate here

91
Q

Name the infraperitoneal/subperitoneal organs

A

-Lower 1/3rd of the rectum
-Distal ureter
-Urinary bladder

92
Q

Describe the embryological development of the testes

A

-Develop in superior posterior abdominal wall, extraperitoneally, from where they descend to the region of the inguinal canal later in foetal development, before reaching scrotum around the time of birth
-Therefore, this is the path along which an undescended testicle may lie
-Undescended testes commonly lie at the level of the superficial ring/inguinal canal

93
Q

What is cryptorchidism?

A

Cryptorchidism is the absence of one or more testis from the scrotum

Note: a retractile testis is a testicle which can be brought into the scrotum with manipulation, but retracts spontaneously or with gentle pressure

94
Q

Name some causes of cryptorchidism

A

Agenesis
Intra-abdominal arrest
Incomplete descent
Ectopic descent

95
Q

What is the difference between orchidopexy and orchidectomy?

A

Orchidopexy is a procedure to bring and fix an undescended testicle into the scrotum

Orchidectomy is the surgical removal of one or both testicles

96
Q

Name some indications for orchidopexy

A

-Treatment of testicular torsion (usually during adolescence)
-Cryptorchidism (usually in children)

Orchidopexy is performed to reduce risks of infertility, testicular malignancy, traumatic injury to the testis, development of inguinal hernia, testicular torsion in adolescents and to maintain appearance of normal scrotum

97
Q

What is a varicocele

A

Dilatation of the pampiniform plexus of veins

98
Q

Where do the left and right testicular veins drain?

A

Left testicular vein: left renal vein

Right testicular vein: IVC at a more oblique angle. Therefore left sided varicoceles are more common

99
Q

What is a hydrocele?

A

A hydrocele is a collection of fluid in the tunica vaginalis, the double layer of peritoneum that invests the testes.

Hydroceles can be primary (idiopathic) or secondary

100
Q

Name some differential diagnoses for scrotal swellings

A

-Epididymal cyst
-Sebaceous cyst
-Testicular malignancy
-Epididymo-orchitis
-Inguinal hernia
-Hydrocele
-Varicocele

101
Q

Describe the course of the ureter

A

-Originates at renal pelvis
-Runs anterior to transverse processes of L1-L5 towards SI joint
-Enters pelvis at bifurcation of common iliac vessels (at pelvic brim) then courses anterior to internal iliac down lateral pelvic sidewall
-Enters bladder posterolaterally at level of ischial spine, courses in wall for 1-2cm before opening into bladder at internal ureteric orifice

102
Q

Name the vessel that crosses the ureter as it enters pelvic brim

A

External iliac artery

103
Q

Describe the relationship of the ureter to the uterine artery in the female pelvis

A

Ureter passes beneath the uterine artery, lateral to the cervix

In males passes beneath the ductus deferens as the ductus courses along lateral wall of pelvis

104
Q

Describe how you would quickly identify the ureter during intra-abdominal surgery

A

-Courses along sacroiliac joints
-Crosses external iliac just distal to iliac bifurcation
-Lies medial to internal iliac on posterolateral pelvic sidewall
-visible peristalsis

105
Q

Name the constrictions of the ureter

A

Pelviureteric junction
Pelvic brim
VUJ

106
Q

Describe the blood supply to the ureter

A

Segmental supply from 4 sources:
-Renal
-Gonadal
-Internal iliac
-Superior and inferior vesical

107
Q

What type of epithelium lines the ureter?

A

Transitional epithelium

108
Q

What serious complication can arise following ureteric obstruction?

A

-Hydronephrosis and renal dysfunction
-Drainage of the kidney is usually required via percutaneous nephrostomy or retrograde ureteric stenting

109
Q

Describe where ureteric calculi may be identified on a plain radiograph of the kidney, ureters and bladder (XR KUB)

A

Course of the ureter can be correlated with bony anatomy visible on a plain film radiograph

–> Passing inferiorly over tips of transverse processes of lumbar vertebrae
–> Passing over SI joint to level of ischial spines then turning medially to enter bladder

110
Q

Name the most common type of ureteric stone (by composition)

A

Calcium oxalate (85% of stones)

111
Q

Name the type of stone (by composition) that is most commonly responsible for staghorn calculi

A

Struvite (can also be calcium oxalate or uric acid)

112
Q

Name the radiolucent stone that occurs in acidic urine

A

Urate stones

113
Q

Other than calculi, name some other causes of unilateral hydronephrosis

A

Intrinsic:
-Stricture
-TCC renal pelvis/ureter

Extrinsic
-Tumour (colonic, cervical, prostatic)
-Abnormal vasculature at PUJ
-Retroperitoneal fibrosis
-Post radiation fibrosis
-AAA

114
Q

What are the functions of the pancreas?

A

Pancreas is an accessory digestive gland with both endocrine and exocrine function s

Endocrine:
-Insulin and glucagon are secreted by the islets of langerhans

Exocrine:
-Secretions from pancreatic acinar cells pass into pancreatic ducts and into duodenum

115
Q

Describe the blood supply to the pancreas

A

Receives supply from coeliac trunk and superior mesenteric artery

Head:
-Superior pancreaticoduodenal: (common hepatic –> gastroduodenal)
-Inferior pancreaticoduodenal: From SMA

Neck, body, tail:
-Branches from splenic artery which runs along superior pancreas

116
Q

What are the posterior relations of the head of the pancreas?

A

-IVC
-Renal veins
-Right renal artery
-Bile duct lies on posterosuperior surface

117
Q

Name the posterior relations of the body of the pancreas?

A

Aorta
SMA
Left kidney, renal vessels, left adrenal

118
Q

Name the posterior relations of the tail of the pancreas

A

Left kidney
Hilum of the spleen
Left colic (splenic) flexure

119
Q

What is the significance of the ampulla of vater?

A

-Marks transition from foregut to midgut
-Is formed by convergence of main pancreatic duct and common bile duct
-Empties via major duodenal papilla into second part of the duodenum

120
Q

What is the most common type of pancreatic malignancy, where is it most commonly anatomically?

A

Adenocarcinoma

70% head
20% body
10% tail

Cancers in head of pancreas may present with obstructive jaundice due to close relation of head with bile duct. Cancers elswhere present late

121
Q

Describe the relations of the spleen

A

Anterior: stomach
Posterior: Left part of diaphragm (separates it form rib 9-11 and lung)
Medial: left kidney
Inferior: Splenic flexure

122
Q

What are the splenic ligaments?

A

Gastrosplenic ligaments
-hilum of spleen –> greater curvature of stomach
-Contains short gastric/left gastroepiploic vessels

Splenorenal ligament
-Runs from hilum of spleen to left kidney
-Contains splenic vessels

Splenocolic
-Spleen–> transverse colon

Splenophrenic
-Spleen–> diaphragm

123
Q

Describe the course of the splenic artery

A

-Originates from coeliac trunk
-Passes along superior pancreas
-Anterior to left kidney
-Divides into 5 branches in splenorenal ligament and enters hilum

124
Q

Describe how splenic injuries may be graded

A

-American association for the surgery of trauma (AAST) has produced grading system based on findings of CT
-Haematoma and laceratinos are graded from:
-Grade 1 (<10% subcapsular haematoma/<1cm capsular tear) to grade V (completely shattered spleen)

125
Q

Describe the management of splenic injuries

A

-Isolated AAST 1/2 injury may be managed conservatively

3-5:
-Haemodynamically stable with signs of bleeding (dropping serial hb)–> IR +/- surgery
-If haemodynamically unstable: resuscitation and emergency laparotomy +/- splenectomy

126
Q

What are current recommendations for post splenectomy prophylaxis?

A

Haemophilus influenza type b vaccine
Meningococcal group c vaccine
Pneumococcal vaccine
Antibiotics for minimum 2 years, preferably lifelong (oral pen v/clarithromycin if pen allergic)
Children: until minimum age 16 (as well as minimum 2 years and preferebly lifelong)

127
Q

Describe the relations of the uterus

A

Anterior: Vesicouterine pouch, bladder
Posterior: recto-uterine pouch (of douglas) and rectum
Lateral: transverse cervical ligament, broad ligament, ureters

128
Q

Describe the arterial supply to the uterus

A

-Predominantly from uterine artery (from internal iliac anterior division)
-Also from ovarian arteries (from abdominal aorta just inferior to renal arteries)

129
Q

Describe the course of the internal iliac artery

A

-Originates at L5-S1 vertebral level at bifurcation of the common iliac artery anterior to sacroiliac joint
-Enters pelvis medial to external iliac vein and obturator nerve
-Terminates into anterior and posterior divisions superior to greater sciatic foramen

130
Q

What territory is supplied by the anterior branch of the internal iliac artery

A

pelvic organs, muscles of pelvis, medial thigh, perineum

131
Q

Name the branches of the anterior division of the internal iliac artery and the territory they supply

A

3 visceral, 3 parietal, 3 urinary

3 parietal
-Inferior gluteal
-Obturator
-internal pudendal

3 visceral
-Uternine
-vaginal
-MIddle rectal

3 urinary
-Superior vesical
-inferior vesical
-umbilical (foetal only)

132
Q

Name the branches of the posterior division of the internal iliac artery and the territory they supply?

A

pILS

Iliolumbar
-Psoas major, iliacus, quadratus lumborum

Lateral sacral
-Piriformis, sacral canal, erector spinae

Superior gluteal
-Piriformis, gluteal muscles, tensor fascia lata

133
Q

Describe the broad ligament of the uterus

A

Double layer of peritoneum within which is folded:
-Uterine tube
-Ligament of ovary
-Round ligament of uterus

-Broad ligament helps fix uterus in place in the pelvis
-Peritoneum which forms broad ligament passes from uterus laterally to side walls + floor of pelvis

134
Q

Describe the course of the ovarian artery

A

-Branch of abdominal aorta, originating inferior to renal arteries
-Descends on posterior abdominal wall where it lies anterior to ureter and gives branches to it
-It then crosses external iliac close to its origin and enters pelvis, where it runs in suspensory ligament of ovary and broad ligament of uterus
-Terminates in branches to ovary and fallopian tube

135
Q

Describe the relations of the vagina

A

Anterior: bladder and urethra

Supero-lateral: ureter

Posterior: ampulla of rectum, pouch of douglas, perineal body, anal canal

Inferiorly: anal canal is seprated from vagina by perineal body

Lateral: levator ani, uterine artery, urogenital diaphragm

136
Q

Which muscles form the pelvic floor?

A

Formed by 3 components of levator ani (pubococcygeus, iliococcygeus and puborectalis)

And coccygeus

137
Q

What are the origins of levator ani?

A

-Originates from posterior of body of pubis bone, spine of ischium, fascia covering obturator internus

138
Q
A
139
Q
A
140
Q

What are the attachments of the ligaments of the pelvis?

A

Sacrospinous ligament: Sacrum  ischial spine
Sacrotuberous ligament: Sacrum  ischial tuberosity

Sacrospinous ligament lies medial to and in front of sacrotuberous ligament

141
Q
A

-Obturator internus and piriformis arise within the pelvis and then exit pelvis via the sciatic foramina
Oburator internus arises from obturator membrane (covers obturator foramen)

142
Q
A

-They exit pelvis through sciatic foramina to insert onto the GT of the femur

143
Q
A
144
Q
A
145
Q
A
146
Q

Describe the insertion of levator ani

A

-Pubococcygeus: forms sling around vagina in female, prostate in male. Inserts into perineal body

-Puborectalis: forms sling around rectum and anus, inserts into anal sphincter

-Iliococcygeus: coxxyx, ano-coccygeal ligament

147
Q

What is innervation to the pelvic floor?

A

Levator ani + coccygeus –> S3+S4 nerve roots

Perineal muscles, external urethral and anal sphincter –> pudendal nerve

148
Q

What is the origin of the pudendal nerve?

A

S2-S4

149
Q

What is the distribution of the pudendal nerve?

A

-Perineum, including perineal muscles and external urethral and anal sphincters
-Sensation to genitalia

150
Q

Pudendal nerve block

A

-Performed for childbirth
-Ischial spines can be palpated inside vagina between 4 and 8 o’clock
-Pudendal nerve passes behind sacrospinous ligament and is found 1cm anteromedial and 1cm posteromedial to ischial spine
-Can be accessed here for anaesthetic blockade

151
Q

Describe orientation of structures in renal hilum vs lung hilum

A

Anterior to posterior:
-renal: VAP (vein, artery, pelvis)
-Lung: VAB (vein, artery, bronchus)

SE book revision (6 decks)

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