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1
Q

Name the avascular spaces in the pelvis

A

Paired

  • Paravesical
  • Pararectal

Unpaired

  • Retropubic space of Retzius
  • Vesicovaginal space
  • Rectovaginal space
  • Presacral space
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2
Q

What’s the most narrow portion of the colon and it’s at what spinal level?

A
  • Rectosigmoid junction
  • Located at S3
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3
Q

Anal Questions

  • How long is the anal canal?
  • The pectinate line divides the anal into?
A

Anal Questions

  • How long is the anal canal?
    • 4 cm
  • The pectinate line divides the anal into?
    • The upper two-thirds and lower third of the anal canal.
    • Developmentally, this line represents the hindgut-proctodeum junction
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4
Q

What’s the significance of the pectinate line?

A
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5
Q

Differences between internal and external sphincter?

A

Internal sphincter

  • Involuntary
  • Smooth muscle

External sphincter

  • Voluntary
  • Skeletal muscle
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6
Q

Name the uterine support structures

A
  1. Broad ligament
  2. Round ligament
  3. Utero-ovarian ligament (ovarian ligament)
  4. Infundibulopelvic (IP) ligament (suspensory ligament of the ovary)
  5. Uterosacral ligament
  6. Cardinal ligament
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7
Q

Ureter lies in what relation to the IP ligament?

A

Medial and posterior to the IP ligament

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8
Q

The utero-ovarian ligament is a remnant of _______

A

gubernaculum

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9
Q

The round ligament is

  • Homologous to _________
  • Embryologically related to _________
A
  • gubernaculum testis
  • utero-ovarian ligament
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10
Q
  • What’s the course of the round ligament?
  • Discuss the clinical significance of the round ligament
A
  • What’s the course of the round ligament?
    • Lateral anterior uterine corpus ⇒ retroperitoneal space ⇒deep inguinal ring⇒inguinal canal⇒superficial inguinal ring⇒ subcutaneous tissue of labia majora.
  • Discuss the clinical significance of the round ligament
    • Lateral to the inferior epigastric vessels on AAW
    • Labial abscess can be due to connection into the peritoneal cavity given the course of the round
    • Contains Sampson’s artery
    • Window into the retroperitoneum especially if you get lost.
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11
Q

What makes up the parametrium?

A

Parametrium = Cardinal ligament + uterosacral ligament

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12
Q

Discuss the significance of the uterosacral ligament

A
  • Attaches cervix to the sacrum (S2-S4)
  • Forms boundaries of pouch of douglas
  • Forms lateral boundaries of presacral space (along with the ureter)
  • Part of level I pelvic support to cervix and upper vagina
  • Contains pelvic autonomic nerves, blood supply, and lymphatics
  • With the cardinal ligament, forms the parametrium.
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13
Q

Significance of the cardinal ligament?

A
  • Thickening of visceral layer of pelvic fascia around uterine artery
  • Attaches cervix & upper vagina ⇒ pelvic sidewall
  • Contains uterine vessels
  • Forms part of Level I pelvic support
  • Forms boundaries of pararectal and paravesical space
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14
Q

Branches of the internal iliac artery?

A

Mnemonic:
I Love Going Places In My Very Own Underwear!
I: iliolumbar artery
L: lateral sacral artery
G: gluteal (superior and inferior) arteries
P: (internal) pudendal artery
I: inferior vesical (vaginal in F) artery
M: middle rectal artery
V: vaginal artery
O: obturator
U: umbilical artery and uterine artery

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15
Q

Describe the course of the internal pudendal artery

A
  • Branch of Anterior Division of internal iliac artery that supplies the perineum
  • Exits pelvis through greater sciatic foramen BELOW piriformis
  • Re-enters pelvis through lesser sciatic foramen
  • Through Alcock’s canal
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16
Q

Branches of the internal pudendal artery?

A
  • Inferior rectal artery
  • Perineal artery
  • Posterior labial arteries
  • Artery of bulb of vesitibule
  • Dorsal artery of clitoris
  • Deep artery of clitoris
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17
Q

External pudendal artery is a branch of _______

Two types of the external pudendal artery include?

A

External pudendal artery is a branch of _______

  • Branch of femoral artery
  • supplies the perineum

Two types of external pudendal artery include?

  • Superficial External pudendal artery – pierces femoral sheath, across round ligament and superficial to inguinal ligament
  • Deep external pudendal artery – passes medially across Pectineus/adductor longus m and anastomose with labial branches
  • Both supply labia majora
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18
Q

Blood supply to the ureter?

A
  • Lots of collateral circulation!
  • Very resilient if transected
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19
Q

Boundaries of the Retropubic Space of Retzius?

A

Anteriorly: Symphysis pubis

Laterally: Pubic rami and obturator internus muscles

Posteriorly: Urinary bladder

Floor: Anterior vagina (in women) and proximal urethra

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20
Q

What is the clinical significance of the Retropubic space of Retzius?

What do you have to be cautious about when entering this space?

A
  • Important for doing exenterations or urogyn procedures such as Burch or slings
  • Veins of Santorini, dorsal artery and vein of clitoris, obturator bundle
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21
Q
  • What are the borders of the vesicovaginal space?
  • What is clinically significant about this space?
A
  • What are the borders of the vesicovaginal space?
    • Anterior – Bladder adventitia
    • Posterior – Vagina/Endopelvic fascia
    • Lateral – Vesicouterine “webs” or vesicouterineligaments or “bladder pillars” (not seen in this picture)
  • What is clinically significant about this space?
    • Allows access to bladder, cervix, vagina, distal ureters
      • Hysterectomy
      • Sacrocolpopexy
      • Vesicovaginal fistula repair
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22
Q
  • What are the borders of the rectovaginal space?
  • What is the clinical significance of this space?
A
  • What are the borders of the rectovaginal space?
    • Anterior- Vagina
    • Posterior- Rectum
    • Lateral- Uterosacral ligaments
  • What is the clinical significance of this space
    • Sacrocolpopexy
    • Rectovaginal fistula repair
    • Low anterior resection
    • Radical hysterectomy
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23
Q

What is the lowest point in the pelvis?

A

Pouch of Douglas

  • aka Rectouterine pouch or Rectovaginal pouch
  • extension of peritoneum between uterus and rectum
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24
Q
  • What are the borders of the presacral space?
  • What is the clinical significance of the presacral space?
A
  • What are the borders of the presacral space?
    • Anterior: Rectum
    • Posterior: Sacrum
    • Superior: Peritoneal reflection of rectum
    • Inferior: Waldeyer’s fascia (3-5 cm proximal to anorectal junction), levator ani
    • Lateral: Uterosacral ligaments, ureter
  • What is the clinical significance of the presacral space?
    • Middle sacral vessel
    • Hypogastric plexus
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25
* What is the clinical significance of presacral fascia? * What is Waldeyer's fascia?
* What is the clinical significance of presacral fascia? * Presacral fascia lines the anterior aspect of the sacrum, enclosing the sacral vessels and nerves. It continues anteriorly as the pelvic parietal fascia, covering the entire pelvic cavity. * The presacral fascia is limited postero-inferiorly, as it fuses with the mesorectal fascia, lying above the levator ani muscle, at the level of the anorectal junction. These two fascias have been erroneously confused, though they are in fact, separate anatomical entities. The colloquial term, among colo-rectal surgeons, for this inter-fascial plane, is known as the holy plane of dissection first coined by Bill Heald. * During rectal surgery and mesorectum excision, dissection along the avascular alveolar plane between these two fascias, facilitates a straightforward dissection and preserves the sacral vessels and hypogastric nerves. * What is Waldeyer's fascia? * Waldeyer's fascia (a.k.a. rectosacral fascia) originates from the presacral parietal fascia at the S2 to S4 level fusing with the rectal visceral fascia at the posterior aspect of the rectum. * Waldeyer's fascia divides the retrorectal space into a superior and inferior compartments.
26
* What are the boundaries of the paravesical space? * What is the clinical significance of this space?
* What are the boundaries of the paravesical space? * Anterior: Pubic symphysis * Posterior: Cardinal Ligament Web * Lateral: External Iliac Vein, obturator internus muscle * Medial: Superior vesical artery * Inferiorly: pelvic floor * What is the clinical significance of this space? * Pelvic LND * Radical hysterectomy * Allows entry into the retropubic space of retzius
27
* What are the boundaries of the pararectal space? * Clinical significance of this space?
* What are the boundaries of the pararectal space? * Anterior: Cardinal Ligament Web * Posterior: Sacrum * Lateral: Internal Iliac Artery * Medial: Ureter, rectum * ureter can be medial or lateral depending on how you mobilize: GYN mobilizes it medially and colorectal mobolizes it laterally. * Clinical significance of this space? * Space is entered for pelvic LND, Radical hysterectomy, or LAR * Allows us entry into the presacral space
28
Give a broad overview of the body's nervous system
29
* What are the two pelvic nerve plexuses?
30
What are the branches of the lumbar plexus?
* Iliohypogastric (L1) * Also receives innervation from T12 * Ilioinguinal (L1) * Also receives innervation from T12 * Genitofemoral (L1-2) * Lateral Femoral Cutaneous (L2-3) * Femoral (L2-4) * Obturator (L2-4)
31
Pathway of the lumbar nerve plexus branches?
* Iliohypogastric (L1) * Comes out most superior and lateral * Ilioinguinal (L1) * Wraps around iliac crest and travels through inguinal ligament * Genitofemoral (L1-2) * Comes through psoas muscle * Lateral Femoral Cutaneous (L2-3) * Comes out lateral to psoas muscle * Femoral (L2-4) * Comes out lateral to psoas muscle * Obturator (L2-4)
32
* What is the function of the genitofemoral nerve? * How is the genitofemoral nerve injured?
* What is the function of the genitofemoral nerve? * Femoral branch: sensory to upper anterior thigh * Genital branch: sensory to mons pubis and labia majora * How is the genitofemoral nerve injured? * Retractor placement or transection
33
* What is the function of the lateral femoral cutaneous nerve? * How is it injured?
* What is the function of the lateral femoral cutaneous nerve? * Sensory to skin of anterior, lateral thigh * How is it injured? * Compression from hyperflexion of hip
34
* What is the function of the femoral nerve? * How is it injured?
* What is the function of the femoral nerve? * Motor to muscles that extend the knee (absent knee jerk if injured) Sensory to upper thigh and inner leg * How is it injured? * Position, retractor placement, childbirth and inguinal node dissection
35
* What is the function of the obturator nerve? * How is the obturator nerve injured?
* What is the function of the obturator nerve? * Motor to adductor muscles of thigh * Sensory to medial, distal thigh * How is the obturator nerve injured? * Transection or injury during pelvic node dissection or sling placement
36
Describe the sensory distribution of the lumbar nerve plexus branches
37
Describe the motor distribution of the lumbar nerve plexus branches
38
* Are sacral nerve plexus branches somatic or autonomic? * Where does the sacral nerve plexus lie? * What does it comprise of? * What are the branches of the sacral nerve plexus branches?
* Are sacral nerve plexus branches somatic or autonomic? * somatic * Where does the sacral nerve plexus lie? * lies on the piriformis muscle * What does it comprise of? * Lumbosacral trunk (L4-5) * Anterior rami of S1-4 * What are the branches of the sacral nerve plexus branches? * Superior gluteal * Inferior gluteal * Posterior femoral cutaneous * Sciatic * Pudendal
39
* What are the nerve roots of the sciatic nerve? * What is the function of the sciatic nerve? * Discuss its course * What are its terminal branches?
* What are the nerve roots of the sciatic nerve? * L4-S3 * What is the function of the sciatic nerve? * Motor and sensory to lower extremity * Discuss its course * Exits pelvis through greater sciatic foramen inferior to the piriformis * Runs along posterior thigh to popliteal fossa * What are its terminal branches? * Tibial nerve – travels to posterior compartment of leg into the foot * Common fibular nerve – travels to anterior and lateral compartments of leg into the foot
40
* What are the nerve roots of the pudendal nerve? * Whare the branches of the pudendal nerve? * Function of the pudendal nerve? * What's the course of the pudendal nerve?
* What are the nerve roots of the pudendal nerve? * S2-S4 * Whare the branches of the pudendal nerve? * inferior rectal nerves * Terminal branches: see figure * Function of the pudendal nerve? * Supplies motor and sensory to all perineal structures * What's the course of the pudendal nerve? * Exits the greater sciatic foramen and enters Alcock's canal to the perineum
41
What is Alcock's canal?
* aka pudendal canal * Formed by obturator internus fascia * Contains internal pudendal artery & veins, pudendal nerve
42
What are the terminal branches of the pudendal nerve?
See figure
43
Describe the somatic and autonomic nerve divisions in the pelvis?
44
What are the differences between sympathetic and parasympathetic fibers?
* Preganglionic fibers * Sympathetic = short * Parasympathetic = long * Postganglionic fibers * Sympathetic = long * parasympathetic = short * Neurotransmitter release * Sympathetic: NE on alpha + Beta receptors * Parasympathetic: ACh on muscarinic receptors
45
Summary slide of nerve plexuses
* Superior hypogastric nerve plexus -\> Right & Left hypogastric nerve * Hypogastric nerve + sacral splanchnic + pelvic splanchnic join to become the inferior hypogastric nerve plexus
46
Superior hypogastric plexus * location? * gives off? * Contents?
Superior hypogastric plexus * location? * Passes over bifurcation of aorta * gives off? * Bifurcates into left and right hypogastric nerves in front of sacrum * Contents? * Mainly post-ganglionic sympathetic fibers * Visceral afferent fibers from pelvis (sympathetic) * Transection for treatment of primary dysmenorrhea * Few parasympathetic postganglionic fibers which head cephalad to innervate the bowel
47
Hypogastric plexus * Branches from? * Location? * Merges with? * Contents? * Surgical ignificance
Hypogastric plexus * Branches from? * Superior hypogastric plexus * Location? * Descend anterior to sacrum and lateral to the rectum * Merges with? * Merge with pelvic + sacral splanchnic nerves to form right and left inferior hypogastric plexuses * Contents? * Carry sympathetic fibers * Surgical significance * Nerves that you see as you are doing a nodal dissection over the sacram or an LAR.
48
Inferior hypogastric plexus * Location? * Formed by? * Gives rise to? * Contents?
Inferior hypogastric plexus * Location? * Lateral to rectum, vagina, base of bladder * Formed by? * Formed by hypogastric and pelvic + sacral splanchnic nerves * Gives rise to? * Gives rise to subsidiary plexuses: middle rectal, uterovaginal, vesical * Contents? * Pre- and post-ganglionic sympathetic fibers * Pre- and post-ganglionic parasympathetic fibers * Visceral afferent fibers * Sympathetic ganglia * Parasympathetic enteric ganglia
49
Pelvic splanchnic nerves * Arises from? * Content?
Pelvic splanchnic nerves * Arises from? * Arise from S2-4 * Content? * Carry parasympathetic fibers and visceral afferent fibers * Pelvic = Parasympathetic
50
Sacral splanchnic nerves * Arises from? * Content?
Sacral splanchnic nerves * Arises from? * Connect inferior hypogastric plexus to sympathetic trunk * Content? * Carry sympathetic fibers * S = Sacral = Sympathetic
51
Which nerves should you be worried about when doing an LAR? What about radical hysterectomy?
* LAR: hypogastric nerves * Rad hyst: inferior hypogastric plexues
52
List the paired and unpaired arterial vessels of the aorta and what they supply
**Unpaired Visceral** * Celiac trunk * Embryonic foregut derivatives and spleen * SMA * Embryonic midgut derivatives * IMA * Embryonic hindgut derivatives **Paired Visceral** * Middle suprarenals * Adrenal (suprarenal) glands * Renals * Kidneys * Gonadal * Ovarian or testicular branches to gonad **Parietal Branches** * Inferior phrenics * Paired arteries to diaphragm * Lumbars * Usually four pairs to posterior abdominal wall and spine * Median sacral * Unpaired artery to sacrum (caudal artery)
53
Where is the renal artery in relation to the renal vein?
Usually superior and posterior
54
Where does the umbilicus lie in relation to vertebrae?
Lies between L3 and L4 vertebrae but T10 innervates the belly but-ten.
55
What are the branches of the aorta in relation to the vertebrae?
56
What is significant about the renal arterial vasculature?
Renal arteries * 35% of patients will have variation in number or location of renal arteries * 28% of anomalies are extra vessels * More likely to be above the usual trunk than below * More common on the left than the right
57
* What is the small bowel supplied by? * Is the vasculature to the small bowel redundant?
* SMA and celiac trunk * Yes, except near the ileo-cecal valve, this is a watershed area.
58
What arterial vasculature supplies the LB?
IMA and SMA
59
* Define the greater and lesser omentum? * Can you remove both these structures? * What connects the greater sac to the lesser sac?
* Define the greater and lesser omentum? * Greater: omentum along greater curvature of stomach * Lesser: omentum along lesser curvature of stomach * Can you remove both these structures? * Yes because both have redundant supply * What connects the greater sac to the lesser sac? * Epiploic foramen (aka Foramen of Winslow)
60
What are boundaries of the Foramen of Winslow?
61
What's the blood supply to the stomach?
Celiac trunk gives off * **L.gastric** * Splenic artery ​ * gives off **left gastroepiploic artery** as heads to spleen * gives off **short gastric artery** * common hepatic * gives off hepatic proper * gives off right and left hepatic arteries * gives off **right gastric artery** * gives off gastroduodenal artery (goes posterior to the stomach) * gives off **right gastroepiploic artery**
62
What supplies the diaphragm?
Phrenic arteries
63
What are diaphragmatic resection pitfalls?
* Hemorrhage * IVC, hepatic veins * Pneumothorax * Hepatic Injury * Phrenic nerve injury * Particularly if other respiratory compromise present
64
What are the ligaments of the liver?
* Coronary ligament * Attaches liver to the diaphragm * Falciform ligament * Divides left and right liver * free edge of this ligament is the round ligament of the liver (ligamentum teres) that attaches to the umbilicus; a remnant of the umbilical vein * Right triangular ligament * Left triangular ligament
65
How do you mobilize the liver?
Animation from GYOedu anatomy * Push down on liver -\> open falciform ligament (splits into coronary ligaments and can see IVC back) * Go lateral and lift up on liver and open the triangular ligaments -\> leads back to coronary ligaments superiorly and inferior and medially you'll have the hepatorenal fossa * Work back and forth to mobilize * Allows you to see whole IVC and hepatic veins. As you mobilize liver, be wary of getting into suprarenal veins
66
Splenic anatomy
67
What do you have to worry about near the splenic hilum?
The tail of the pancreas
68
What are the attachments of the spleen?
* phrenicosplenic ligament * typically avascular * gastrosplenic ligament * continuation of greater omentum * contains short gastric artery * splenorenal ligament * splenocolic ligament * typically avascular
69
What are the layers of the bladder?
* Mucosa * transitional epithelium * lamina propria * Detrusor muscle * Adventitia
70
* What are the branches of the celiac trunk? * Which artery has the largest diameter? * What has the smallest diameter
* What are the branches of the celiac trunk? * splenic * left gastric * common hepatic * Which artery has the largest diameter? * splenic * What has the smallest diameter * left gastric
71
How do you expose the anatomy to gain access to the celiac trunk?
Mobilize stomach inferiorly and expose lesser omentum
72
What is the blood supply to the stomach? What are their origins?
* Right gastric artery * common hepatic artery * Left gastric artery * celiac trunk * Right gastroepiploic artery * common hepatic -\> gastroduodenal artery * Left gastroepiploic artery * splenic artery * Short gastrics * splenic artery
73
What is Auerbach's plexus?
Plexus of nerves that cause stomach peristalsis
74
What are the four sections of the stomach? What do G-cells of the stomach produce?
Four sections of the stomach? * ​Cardia * fundus * body * pylorus What do G-cells of the stomach produce? * Gastrin (stimulates secretion of gastric acid by parietal cells)
75
What is the blood supply to the spleen?
Splenic artery and splenic vein
76
How much volume of red blood cells are contained at one time in the spleen?
It contains 250 ml of blood
77
* How many segments are there in the liver? * How many lobes are in the liver?
* How many segments are there in the liver? * 8 * Functional segments (Couinaud segments) * How many lobes are in the liver? * 4 * Right * Segment V-VIII * Left * Segment II - IV * Caudate * Segment I * Quadrate * Segment IVb
78
* What is the blood flow to the liver (with percentages)? * What percentage of the liver do you need for full complete regeneration?
* What is the blood flow to the liver? * Common hepatic (25%) * Portal vein (75%) * What percentage of the liver do you need for full complete regeneration? * 25%
79
What are the structures of the portal triad?
* hepatic artery * portal vein * bile duct
80
* How would you gain exposure to the pancreas? * What two major blood vessels are immediately in front and behind neck of pancreas? * What is the blood supply to the pancreas? * What is the ideal conservative management of a pancreatic leak? * The pancreatic duct and common bile duct form the \_\_\_\_?
* How would you gain exposure to the pancreas? * Enter lesser sac by dissecting the omentum off the transverse colon * What two major blood vessels are immediately in front and behind neck of pancreas? * SMA and SMV * What is the blood supply to the pancreas? * splenic artery, superior and inferior pancreaticoduodenal artery * What is the ideal conservative management of a pancreatic leak? * NPO, TPN, and octreotide * The pancreatic duct and common bile duct form the\_\_\_? * Ampula of Vater (hepatopancreatic ampula) * Name of the sphincter = Sphincter of Oddi
81
* What is the blood supply to the duodenum? * What is the function of the duodenum?
* What is the blood supply to the duodenum? * Celiac trunk⇒common hepatic⇒superior **_pancreaticoduodenal artery_** * SMA⇒**_inferior pancreaticoduodenal artery_** * What is the function of the duodenum? * Releases bicarbonate (Brunner’s glands) to neutralize stomach acids
82
Where are Peyer's patches located?
ileum (supports digestive tract local immune system)
83
What is the normal length of small bowel?
* Average = 480 cm * Ranges from 300 - 800 cm
84
What is the length of the large intestine?
1.5 meters or 5 feet
85
What are the 6 segments of large intestine? Which segments have the largest and smallest diameter?
* Cecum (largest) * Ascending * Transverse * Descending (smallest diameter) * Sigmoid * Rectum
86
What is the name of the valve between the appendix and the cecum?
Gerlach's valve
87
* Where does the superior epigastric artery originate? * Where does the inferior epigastric artery originate? * Where does the circumflex iliac arteries originate?
* Where does the superior epigastric artery originate? * Internal thoracic artery * Where does the inferior epigastric artery originate? * External iliac artery * Where does the circumflex iliac arteries originate? * Superficial: femoral artery * Deep: external iliac artery
88
At what level along the abdominal wall do the superior & inferior epigastric anastomose?
Umbilicus
89
What is the origin of the superior rectal artery?
IMA
90
What is the origin of the inferior rectal artery?
Internal pudendal artery
91
* What is the only major abdominal artery that does not have an equivalent vein? * What is the largest glandular organ in the body? * What is another name for the anocutaneous line inferior to the pectinate line? * What is the fastest muscle in your body?
* What is the only major abdominal artery that does not have an equivalent vein? * celiac artery * What is the largest glandular organ in the body? * liver * What is another name for the anocutaneous line inferior to the pectinate line? * White line of Hilton * What is the fastest muscle in your body? * orbicularis oculi
92
What are branches of the common hepatic artery?
* proper hepatic artery * right gastric artery * gastroduodenal artery
93
Branches of the left gastric artery?
* Esophagageal branch * Stomach branch
94
What are the branches of the splenic artery?
* dorsal pancreatic artery * short gastrics * left gastro-omental artery * greater pancreatic artery
95
* What is the portal triad? * How do you stop hemorrhaging from one of those vessels or from a large liver laceration?
* What is the portal triad? * Hepatic artery * Common bile duct * Portal vein * How do you stop hemorrhaging from one of those vessels or from a large liver laceration? * Pringle maneuver * Consists in clamping the hepatoduodenal ligament (the free border of the lesser omentum). This can be achieved using: 1) a large atraumatic hemostat (soft clamp) 2) manual compression 3) vessel loop or umbilical tape. * This interrupts the flow of blood through the hepatic artery and the portal vein, which helps to control bleeding from the liver. The common bile duct is also temporarily closed during this procedure. * Interruption \> 120 minutes of intermittent occlusion can lead to re-perfusion injury
96
What are the branches of the external iliac artery?
* Femoral artery * Inferior epigastric artery * Deep circumflex artery
97
What happens if you ligate the IMA?
* No problem as long as you have the marginal artery (artery of Drummond) * anastomosis the IMA and SMA * Be wary if you do sacrifice the IMA (e.g. doing a sigmoid resection or colostomy) and take the marginal artery of drummond (e.g. doing ileo-cecal resection, etc)
98
What are the borders of a pelvic lymph node dissection?
* Superior: distal half of the common iliac artery * Lateral: genital femoral nerve * Medial: superior vesical artery * Inferior: deep circumflex iliac vein * Deep: obturator nerve
99
What vascular anomaly do you need to wary about when doing a pelvic lymph node dissection?
* 25% of patients will have an aberrant obturator vein
100
What are the borders of a para-aortic lymph node dissection?
* Cephalic: renal arteries (at least IMA) * Caudal: mid common iliac artery * Lateral: ureter
101
What is the function of the ilioinguinal nerve? How is it injured?
Sensation to the groin, inner thigh, and labia majora. Injured by nerve entrapment, transverse incision
102
* What is the function of the sciatic nerve? * Nerve branches? * Manifestation of injury?
* What is the function of the sciatic nerve? * Motor: distal extremity – hip extension, knee flexion * Sensation: below the knee except medial foot * Nerve branches? * Peroneal and tibial nerves * Manifestation of injury? * Peroneal injury - foot drop
103
* What muscles make up the pelvic diaphragm? * What muscles make up the levator ani?
* What muscles make up the pelvic diaphragm? * Levator ani * coccygeus * What muscles make up the levator ani? * puborectalis * pubococcygeus * ileococcygeus
104
What are the contents of the femoral triangle?
NAVEL (Pneumonic) (Venous near your penis) * **N**erve * **A**rtery * **V**ein * **E**mpty space * **L**ymphatics
105
What are the borders of the femoral triangle?
* Superior: Inguinal ligament * Medial: _medial_ border of adductor longus muscle * Lateral: medial border of sartorius muscle
106
Define the superficial inguinal lymph nodes
* Inguinal lymph nodes that form a chain immediately below the inguinal ligament. They lie deep to the fascia of Camper that overlies the femoral vessels at the medial aspect of the thigh. * Divided into 3 groups 1. Superomedial superficial inguinal: located at the middle of the saphenous opening, take drainage from the perineum and genitals. 2. Superolateral superficial inguinal: on the side of the saphenous opening, receive drainage from the side buttocks and the lower abdominal wall. 3. Inferior superficial inguinal: inferior of the saphenous opening of the leg, receive drainage from lower legs.
107
Define the deep inguinal lymph nodes.
* Lie medial to the femoral vein under the cribriform fascia. * The uppermost node is in the groin, under the inguinal ligament, and is called Cloquet's node * It can also be considered as the lowest of the external iliac lymph nodes.
108
What is cloquet's node?
* The uppermost node is in the groin, under the inguinal ligament, and is called Cloquet's node (also Rosenmuller's node). * This node is named for French surgeon Jules Germain Cloquet or for German anatomist Johann Christian Rosenmüller. * It can also be considered as the lowest of the external iliac lymph nodes
109
What makes up the floor of the femoral triangle?
* Iliacus * Psoas major * Pectineus * Adductor longus muscle
110
What are the branches of the femoral artery/vein?
* Femoral artery branches * superficial iliac circumflex * superficial epigastric * superficial external pudendal * deep external pudendal * Femoral vein branches * superficial iliac circumflex * superficial epigastric * superficial external pudendal * deep external pudendal * Great saphenous vein
111
What are the vasculature structures that go through the saphenous opening?
* Branches of femoral artery * superficial epigastric * superficial external pudendal * superficial circumflex iliac * Branches of the femoral vein * Great saphenous vein * superficial epigastric * superficial external pudendal * superficial circumflex iliac
112
What is the saphenous opening?
* Aka Fossa ovalis of the thigh * Oval opening in the fascia lata in the upper medial part of the front of the thigh. * The center of the opening is about 4 cm below and lateral to the pubic tubercle. Its vertical length measures about 3–4 cm and 1.5 cm long. * The saphenous opening is closed by the membrane of superficial fascia: **cribriform fascia** * **​**This fascia is pierced by a number of vascular structures.
113
What are the anatomical differences between jejunum and ileum?
* luminal diameter * bowel wall thickness * Amount of fat mesentery * Amount of loop arcades * length of vasa recta

Surgery (5 decks)

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