AbdoPelvis A COPY

Question 1

Which of the following is not a content of the porta hepatis? A. Portal vein B. Hepatic artery C. Cystic duct D. Hepatic lymph nodes E. None of the above

Answer 1

The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The structures in the porta hepatis are: Portal vein Hepatic artery Common hepatic duct

Question 2

A surgeon is due to perform a laparotomy for perforated duodenal ulcer. An upper midline incision is to be performed. Which of the following structures is the incision most likely to divide? A. Rectus abdominis muscle B. External oblique muscle

Answer 2

Linea AlbaUpper midline abdominal incisions will involve the division of the linea alba. Division of muscles will not usually improve access in this approach and they would not be routinely encountered during this incision.

Question 3

Question 6 of 328 A 59 year old man is undergoing an extended right hemicolectomy for a carcinoma of the hepatic flexure of the colon. The surgeons divide the middle colonic vein close to its origin. Into which of the following structures does t

Answer 3

SMVThe middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur and be difficult to control.

Question 4

Question 18 of 328 Which of the following nerves passes through the greater sciatic foramen and innervates the perineum? A. Pudendal B. Sciatic C. Superior gluteal D. Inferior gluteal E. Posterior cutaneous nerve of the thigh

Answer 4

Pudendal3 divisions of the pudendal nerve: Rectal nerve Perineal nerve Dorsal nerve of penis/ clitorisAll these pass through the greater sciatic foramen.The pudendal nerve innervates the perineum. It passes between piriformis and coccygeus medial to the sciatic nerve.

Question 5

Question 37 of 328 A 53 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. From which embryological structure is this region of the gastrointestinal tract derived? A. Vitellino-intestinal duct B. Hind

Answer 5

Hind GutThe left colon is embryologically part of the hind gut. Which accounts for its separate blood supply via the IMA.

Question 6

Question 42 of 328 You excitedly embark on your first laparoscopic cholecystectomy and during the operation the anatomy of Calots triangle is more hostile than anticipated. Whilst trying to apply a haemostatic clip you avulse the cystic artery. T

Answer 6

Right hepatic arteryThe cystic artery is a branch of the right hepatic artery. There are recognised variations in the anatomy of the blood supply to the gallbladder. However, the commonest situation is for the cystic artery to branch from the right hepatic artery.

Question 7

Question 43 of 328 A 43 year old man suffers a pelvic fracture which is complicated by an injury to the junction of the membranous urethra to the bulbar urethra. In which of the following directions is the extravasated urine most likely to pass?

Answer 7

Anteriorly into the connective tissues surrounding the scrotumThe superficial perineal pouch is a compartment bounded superficially by the superficial perineal fascia, deep by the perineal membrane (inferior fascia of the urogenital diaphragm), and laterally by the ischiopubic ramus. It contains the crura of the penis or clitoris, muscles, viscera, blood vessels, nerves, the proximal part of the spongy urethra in males, and the greater vestibular glands in females.When urethral rupture occurs as in this case the urine will tend to pass anteriorly because the fascial condensations will prevent lateral and posterior passage of the urine.

Question 8

Question 47 of 328 During the course of a radical gastrectomy the surgeons detach the omentum and ligate the right gastro-epiploic artery. From which vessel does it originate? A. Superior mesenteric artery B. Inferior mesenteric artery C.

Answer 8

Gastroduodenal arteryThe gastroduodenal artery arises at the superior part of the duodenum and descends behind it to terminate at its lower border. It terminates by dividing into the right gastro-epiploic artery and the superior pancreaticoduodenal artery. The right gastro-opiploic artery passes to the left and passes between the layers of the greater omentum to anastomose with the left gastro-epiploic artery.

Question 9

Question 50 of 328 Through which of the following foramina does the genital branch of the genitofemoral nerve exit the abdominal cavity? A. Superficial inguinal ring B. Sciatic notch C. Obturator foramen D. Femoral canal E. Deep ingu

Answer 9

Deep inguinal ringThe genitofemoral nerve divides into two branches as it approaches the inguinal ligament. The genital branch passes anterior to the external iliac artery through the deep inguinal ring into the inguinal canal. It communicates with the ilioinguinal nerve in the inguinal canal (though this is seldom of clinical significance).

Question 10

Question 53 of 328 A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the uterine body. To which nodal region will the tumour initially metastasise? A. Para aortic nodes B. Iliac lymph nodes C. Inguinal nod

Answer 10

Iliac lymph nodesTumours of the uterine body will tend to spread to the iliac nodes initially. Tumour expansion crossing different nodal margins this is of considerable clinical significance, if nodal clearance is performed during a Wertheims type hysterectomy

Question 11

Question 55 of 328 Which of the following structures is not located in the superficial perineal space in females? A. Posterior labial arteries B. Pudendal nerve C. Superficial transverse perineal muscle D. Greater vestibular glands E

Answer 11

The pudendal nerve is located in the deep perineal space and then branches to innervate more superficial structures.

Question 12

Question 56 of 328 Which of the following is not a branch of the hepatic artery? A. Pancreatic artery B. Cystic artery C. Right gastric artery D. Right hepatic artery E. Right Gastroepiploic artery

Answer 12

The pancreatic artery is a branch of the splenic artery.

Question 13

Question 58 of 328 A 56 year old man is undergoing a nephrectomy. The surgeons divide the renal artery. At what level do these usually branch off the abdominal aorta? A. T9 B. L2 C. L3 D. T10 E. L4

Answer 13

The renal arteries usually branch off the aorta on a level with L2.

Question 14

Question 60 of 328 A 22 year old man presents with appendicitis. At operation the appendix is retrocaecal and difficult to access. Division of which of the following anatomical structures should be undertaken? A. Ileocolic artery B. Mesentery

Answer 14

Lateral peritoneal attachments of the caecumThe commonest appendiceal location is retrocaecal. Those struggling to find it at operation should trace the tenia to the caecal pole where the appendix is located. If it cannot be mobilised easily then division of the lateral caecal peritoneal attachments (as for a right hemicolectomy) will allow caecal mobilisation and facilitate the procedure.

Question 15

Question 64 of 328 A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum. What is the most likely explanation? A. Psychosexual issues related to an end colostomy B. Damage to the sacral venous plex

Answer 15

Damage to the hypogastric plexus during mobilisation of the inferior mesenteric arteryAutonomic nerve injury is the most common cause

Question 16

Question 65 of 328 A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To which of the following lymph nodes will the tumour drain primarily? A. Para aortic B. Internal iliac C. Superficial ingu

Answer 16

The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first site.

Question 17

Question 78 of 328 A 28 year old man has sustained a non salvageable testicular injury to his left testicle. The surgeon decides to perform an orchidectomy and divides the left testicular artery. From which of the following does this vessel originate

Answer 17

Abdominal AortaThe testicular artery is a branch of the abdominal aorta.

Question 18

Question 82 of 328 A 44 year old man is stabbed in the back and the left kidney is injured. A haematoma forms, which of the following fascial structures will contain the haematoma? A. Waldeyers fascia B. Sibsons fascia C. Bucks fascia D

Answer 18

Gerotas FasciaWaldeyers fascia- Posterior ano-rectumSibsons fascia- Lung apexBucks fascia- Base of penisGerotas fascia- Surrounding kidneyDenonvilliers fascia- Between rectum and prostate

Question 19

Question 90 of 328 Which of the following structures is not directly related to the right adrenal gland? A. Diaphragm posteriorly B. Bare area of the liver anteriorly C. Right renal vein D. Inferior vena cava E. Hepato-renal pouc

Answer 19

The right renal vein is very short and lies more inferiorly.

Question 20

Question 92 of 328 Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following? A. Abdominal oesophagus B. Duodenum C. Right colic flexure D. Right kidney E. Pylorus of stomach

Answer 20

Abdominal oesophagusThe fundus of the stomach is a posterior relation. The pylorus lies more inferolaterally. During a total gastrectomy division of the ligaments holding the left lobe of the liver will facilitate access to the proximal stomach and abdominal oesophagus. This manoeuvre is seldom beneficial during a distal gastrectomy.

Question 21

Question 99 of 328 At what level does the aorta bifurcate into the left and right common iliac arteries? A. L1 B. L2 C. L3 D. L4 E. L5

Answer 21

L4The aorta typically bifurcates at L4. This level is usually fairly constant and is often tested in the exam.

Question 22

Question 106 of 328 A 32 year old man presents with an inguinal hernia and undergoes an open surgical repair. The surgeons decide to place a mesh on the posterior wall of the inguinal canal to complete the repair, which of the following structure

Answer 22

Transversalis fasciaInguinal canal walls: ‘MALT: 2M, 2A, 2L, 2T’:Starting from superior, moving around in order to posterior:Superior wall (roof): 2 Muscles:Internal oblique, transversus abdominisAnterior wall: 2 Aponeuroses: Aponeurosis of external oblique, Aponeurosis of internal obliqueLower wall (floor): 2 Ligaments: Inguinal Ligament, Lacunar Ligament Posterior wall: 2Ts: Transversalis fascia, Conjoint TendonThis is actually quite a straightforward question. It is simply asking for the structure that forms the posterior wall of the inguinal canal. This is composed of the transversalis fascia, the conjoint tendon and more laterally the deep inguinal ring.

Question 23

Question 120 of 328 A 22 year old man is involved in a fight outside a nightclub. He is stabbed in the back, on the left side, approximately 3cm below the 12th rib in the mid scapular line. The structure most likely to be injured first as a resul

Answer 23

The left kidney lies in this location and is the most likely structure to be injured. The Spleen lies more superiorly, and the left adrenal and ureter are unlikely to be injured in isolation.

Question 24

Question 127 of 328 A 23 year old man is undergoing an hernia repair and the mesh is to be sutured to the inguinal ligament. From which of the following does the inguinal ligament arise? A. Transversus abdominis fascia B. Internal oblique

Answer 24

The inguinal ligament is formed by the external oblique aponeurosis. It runs from the pubic tubercle to the anterior superior iliac spine.

Question 25

Question 130 of 328 A 56 year old man is undergoing a high anterior resection. Which of the following structures is at greatest risk of injury in this procedure? A. Superior mesenteric artery B. Left ureter C. External iliac vein D.

Answer 25

Left UreterA careless surgeon may damage all of these structures. However, the structure at greatest risk and most frequently encountered is the left ureter.

Question 26

Question 134 of 328 A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which of the following structures

Answer 26

The portal vein, hepatic artery and common bile duct are occluded.

Question 27

Question 136 of 328 A 56 year old lady undergoes a Hartmans style resection of the sigmoid colon, with ligation of the vessels close to the colon. Which of the following vessels will be responsible to supplying the rectal stump directly? A. Supe

Answer 27

Superior rectal arteryThis question is addressing the blood supply to the rectum. Which is supplied by the superior rectal artery. High ligation of the IMA may compromise this structure. However, the question states that during the Hartmans procedure the vessels were ligated close to the bowel. Implying that the superior rectal was preserved.

Question 28

Question 140 of 328 On inspecting the caecum, which of the following structures is most likely to be identified at the point at which all the tenia coli converge? A. Gonadal vessels B. Appendix base C. Appendix tip D. Ileocaecal val

Answer 28

Question 140 of 328 On inspecting the caecum, which of the following structures is most likely to be identified at the point at which all the tenia coli converge? A. Gonadal vessels B. Appendix base C. Appendix tip D. Ileocaecal val

Question 29

Question 146 of 328 An elderly lady falls and lands on her hip. On examination her hip is tender to palpation and x-rays are taken. There are concerns that she may have an intertrochanteric fracture. What is the normal angle between the femoral n

Answer 29

130The normal angle between the femoral head and shaft is 130o. Changes to this angle may occur as a result of disease or pathology and should be investigated.

Question 30

Question 149 of 328 Which of the following structures lies most posteriorly at the porta hepatis? A. Cystic artery B. Common hepatic artery C. Left hepatic artery D. Portal vein E. Common bile duct

Answer 30

The portal vein is the most posterior structure at the porta hepatis.The common bile duct is a continuation of the common hepatic duct and is formed by the union of the common hepatic duct and the cystic duct.

Question 31

Question 150 of 328 A 76 year old man is undergoing an abdominal aortic aneurysm repair. The surgeons occlude the aorta with two clamps, the inferior clamp being placed at the point of aortic bifurcation. Which of the following vertebral bodies will

Answer 31

L4Theme from September 2013 ExamThe aorta bifurcates at L4. An important landmark that is tested frequently.

Question 32

Question 151 of 328 Which of the following statements relating to the greater omentum is false? A. It is less well developed in children under 5. B. It has no relationship to the lesser sac. C. It contains the gastroepiploic arteries. D

Answer 32

It has no relationship to the lesser sac.It is connected with the lesser sac and the transverse colon. This plane is entered when performing a colonic resection. It is a common site of metastasis in many visceral malignancies.

Question 33

Question 152 of 328 A 48 year old man with newly diagnosed hypertension is found to have a phaeochromocytoma of the left adrenal gland and is due to undergo a laparoscopic left adrenalectomy. Which of the following structures is not directly related

Answer 33

Lesser curvature of the stomachThe left adrenal gland is slightly larger than the right. It is crescent in shape and its concavity is adapted to the medial border of the upper part of the left kidney. The upper area is covered by peritoneum of the omental bursa which separates it from the cardia of the stomach. The lower area is in contact with the pancreas and splenic artery and is not covered by peritoneum. On the anterior surface is a hilum from which the suprarenal vein emerges. The lateral aspect rests on the kidney. The medial is small and is on the left crus of the diaphragm.

Question 34

Question 156 of 328 An 18 year old boy is undergoing an appendicectomy for appendicitis. At which of the following locations is the appendix most likely to be found? A. Pre ileal B. Pelvic C. Retrocaecal D. Post ileal E. None of the

Answer 34

RetrocaecalMost appendixes lie in the retrocaecal position. If a retrocaecal appendix is difficult to remove then mobilisation of the right colon significantly improves access.

Question 35

Question 157 of 328 A 56 year old man is undergoing a pancreatectomy for carcinoma. During resection of the gland which of the following structures will the surgeon not encounter posterior to the pancreas itself? A. Left crus of the diaphrag

Answer 35

Gastroduodenal arteryTheme from 2010 ExamThe gastroduodenal artery lies anterior to the pancreas.

Question 36

Question 164 of 328 A 55 year old man is admitted with a brisk haematemesis. He is taken to the endoscopy department and an upper GI endoscopy is performed by the gastroenterologist. He identifies an ulcer on the posterior duodenal wall and spends an

Answer 36

Common hepatic arteryThe vessel will be the gastroduodenal artery, this arises from the common hepatic artery.

Question 37

Question 167 of 328 Which of the following vessels does not drain directly into the inferior vena cava? A. Superior mesenteric vein B. Right common iliac C. Right hepatic vein D. Left hepatic vein E. Right testicular vein

Answer 37

Superior mesenteric veinThe superior mesenteric vein drains into the portal vein. The right and left hepatic veins drain into it directly, this can account for major bleeding in more extensive liver shearing type injuries.

Question 38

Question 168 of 328 A 17 year old male has a suspected testicular torsion and the scrotum is to be explored surgically. The surgeon incises the skin and then the dartos muscle. What is the next tissue layer that will be encountered during the dissect

Answer 38

External spermatic fasciaThe layers that will be encountered are (in order):1. Skin2. Dartos fascia and muscle3. External spermatic fascia4. Cremasteric muscle and fascia5. Internal spermatic fascia6. Parietal layer of the tunica vaginalisThe layers of the spermatic cord and scrotum are a popular topic in the MRCS exam.

Question 39

Question 171 of 328 A 19 year old man undergoes an open inguinal hernia repair. The cord is mobilised and the deep inguinal ring identified. Which of the following structures forms its lateral wall? A. External oblique aponeurosis B. Transver

Answer 39

The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric vessels form its inferomedial wall.

Question 40

Question 174 of 328 During an inguinal hernia repair the surgeon identifies a small nerve whilst mobilising the cord structures at the level of the superficial inguinal ring. Which nerve is this most likely to be? A. Subcostal B. Iliohypogast

Answer 40

IlioinguinalIlioinguinal nerve entrapment may be a cause of neuropathic pain following inguinal hernia surgery.The ilioinguinal nerve passes through the superfical inguinal ring and is routinely encountered when exploring the inguinal canal during hernia surgery. The iliohypogastric nerve pierces the aponeurosis of the external oblique muscle superior to the superficial inguinal ring.