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mr C.S. > Anatomy: Abdomen, Pelvis and Perineum > Flashcards

Anatomy: Abdomen, Pelvis and Perineum Flashcards

1
Q

Why is ischiorectal fossa important clinically?

A

Infection can results - mainly spreading from boils from perianal skin, lesions within the rectum / anal canal, collections bursting through levator ani

Because fossa can communicate - can easily pass infection from one side to the other

Pudendal nerves in pudendal canal (on the lateral wall of the fossa) can be blocked in forceps delivery

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2
Q

Vaginal examination features

A

Inspect during straining = prolapse / stress incontinence

Anterior: pubis, urethra, bladder

Posterior: rectum, pouch of douglas = any invasion into posterior vaginal wall / malignant deposits

Apex: cervix - in anterverted - anterior lip, in retroverted - os or posterior lip can be felt first + cervical neoplasia

Bimanual = assess uterus size, pelvic size, postioin/texture of uterus, ovarian enlargement, abnormalities of fallopian tube

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3
Q

Relations of the spleen

A

Anteriorly: stomach

Posteriorly: left diaphragm, separating it from left pleura, lung, ribs 9, 10, 11

Inferiorly: splenic flexure of colon

Medially: left kidney

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4
Q

Route of the sperm (+ vas deferens anatomy)

A

Semineferous ducts in the lobules of the testis

Rete testes

Vasa in the epididymis

Into the vas deferens: 45cm, thick muscular tube

Through the scrotum - inguinal canal - lateral wall of the pelvis below the peritoneum - towards the ischial spine - turns medially towards base of bladder

Unites with seminal vesicles to form the common ejaculatory ducts

Enter bladder at the most superior and posterior aspect

Traverses bladder and opens in prostatic urethra at the verumonatnum - either side of the utricle

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5
Q

Capsules of the prostate

A

True capsule: thin, fibrous sheath surrounding the prostate

False capsule: condensation of the extraperioenal fascia, continuous with the fascia of the bladder and fascia of denonvilliers

Third capsule: sometimes created in BPH due to condensation of the periopheral part of the prostate gland

In enucleation of the prostate for BPH- the plane between the adenomatous mass and third capsule is enteredbetween te

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6
Q

Where is the venous plexus of the prostate?

A

In between the true and false fascia

True: thin fibrous capsule

False: condensation of the extraperitoneal fascia - continuous wiht the fascia around the bladder, and the fascia of denonvilliers posteriorly

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7
Q

Contents of the spermatic cord

A

3 layers of fascia

external spermatic (from ext oblique apo)
cremasteric (from int oblique apo)
internal spermatic (from transversalis fascia)

3 arteries

testicular
cremasteric
artery to the vas

3 nerves

sympathetic
ilioinguinal (lies on the cord)
genital branch of the genitofemoral N (to cremaster)

3 other things

vas deferens
pampiniform plexus of the veins
lymphatics

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8
Q

Main tributaries of the IVC

A

Lumbar branches

Right gonadal vein

Right renal vein

Left renal vein

Right suprarenal vein

Phrenic vein

Hepatic vein

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9
Q

Internal oblique

Origin

Insertion

Direction of fibres

A

Anterior 2/3 iliac crest, lumbodorsal fascia, lateral 2/3 inguinal ligament

linea alba, ribs 11/12, pubic crest via conjoint tendon

Upwards and medially

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10
Q

Parts of the penis

A

Root

Body

Glans

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11
Q

Transverse colon features

Relations: anterior, posterior, superior, inferior

A

Covered in mesentery - transverse mesocolon attached to the anterior surface of the pancreas

Becomes descending colon at the splenic flexure

Superiorly: liver, gallbladder, greater curvature of stomach, spleen

Inferiorly: coils of small intestine

Anteriorly: greater omentum

Posteriorly: right kidney, small intestine, left kidney, second part of duodenum, pancreas

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12
Q

Devleopment abnormalities in the kidney

A

Metanephric duct structures fails to fuse with metanephros structures = ARPKD

Metanephric duct may branch early - extra ureters; may extend into urethra/vagina - causing incontinence

Metanephros fails to develop one side - congenital absence of kidney

Two metanephric masses may fuse = horseshoe kidney

Kidney fail to migrate = pelvic kidney

Distal arteries may persist = aberrant renal arteries,

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13
Q

Subcostal (Kocher’s)

Indications

Process

Structures encountered

Risks

A

Cholecystectomy (right) / elective splenectomy (left) / Anterior approach for kidneys (both connected in middle)

2.5cm below and parallel to costal margin, extending laterally to border of rectus sheath or further

Skin, subcut fat, campers, scarpas, anterior rectus sheath, rectus abdominis, posterior rectus sheath, extraperitoneal fat, peritoneum

9th intercostal nerve near the lateral border of incision - if damaged - weakness and atrophy of upper rectus - predisposing to incisional hernia

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14
Q

Iliacus

Origin

Insertion

Nerve supply

Action

A

Greater part of iliac fossa extending onto sacrum

Lateral part of psoas major tendon onto the lesser trochanter

branch of femoral nerve (L2-L3)

Flexion of vetebral column

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15
Q

Rectus sheath:

above costal margin

above arcuate line

below arcuate line

A

Fuses in the middle = linea alba - xiphisternum - pubic symphysis

Anterior: External oblique only

Anterior: external oblique + 1/2 internal oblique
Posterior: transversus abdominis + 1/2 internal oblique; transversalis fascia, peritoneum

Anterior: external oblique + internal oblique + transversus; transversalis fascia + peritoneum

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16
Q

Distinguishing between jejunum and ileum

A

Jejunum is thicker as valvulae coniventes / plicae circulares are larger and more numerous

Greater diameter

Mesentery at jejunum - less arcades that are longer and straigher (less arches), less fatty and thinner vs lower down

Found at or above level of the umbilicus, whilst ileum more likely below

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17
Q

Quadratus lumborum

Origin

Insertion

Nerve supply

Action

A

Iliolumbar ligament and adjacent portion of iliac crest

Into the lower border of 12th rib medially and tendons into L1-L4 transverse processes

T12-L4

Extension and lateral flesion of lumbar vertebrae; fixes 12th rib during inspiration

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18
Q

Nerve supply of the oesophagus

Upper third

Below the root of the lung

A

Upper third: parasympathetic via RLN + sympathetic via middle cervical ganglion along inferior thyroid artery

Below root of the lung: Vagus + sympathetic nerves form the oesophageal plexus

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19
Q

Stomach

Anatomy: shape, surfaces, curves, orifices

Junction of body and pyloric antrum is called?

Pylorus with duodenum junction?

A

J shape, anterior and posterior surface, greater and lesser curvature, cardia and pylorus orifice

Cardia, body (with fundus at the top - lies above cardia), pylorus (antrum and canal)

Incisura angularis

constant prepyloric veins of Mayo - crosses it vertically

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20
Q

Location of the deep inguinal ring

Important structure next to it

A

1cm above the midpoint of the inguinal ligament

Defect in the transversalis fascia

Located laterally to the inferior epigastric vessels

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21
Q

Blood supply of the spleen

A

Splenic artery from coeliac trunk (runs along upper border of pancreas)

Splenic vein - behind the pancreas

Splenic vessels + tail of the pancreas in the lieno-renal ligament + lymph nodes

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22
Q

Composition of the perineum

A

Anterior triangle (urogenital)

Posterior triangle (anal)

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23
Q

Relations of the pancreas

  • anterior / posterior

Splenic vessels

A

The stomach and D1 lie in front of the pancreas - separated by mesentery (pancreas is retroperitoneal)

Transverse mesocolon attached to the anterior aspect of the pancreas

Below this is the DJ flexure, splenic flexure, small intestine

Posteriorly in contact with the left crus of the driaphragm, the aorta, left suprarenal gland and left kidney

Splenic artery = along upper border of pancreas

Splenic vein = being pancreas

Main duct from tail to head; accessory duct opens 2cm proximally in duodenum

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24
Q

Sites of narrowing of oesophagus

A

Commencement - 17cm from upper incisors

Where its crossed by left main bronchus - 28cm from upper incisors

Termination - 43cm from upper incisors

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25
Q

Layers to get to the testes

A

Skin

Dartos muscle

External spermatic fascia

Cremasteric muscle within cremasteric fasacia

Internal spermatic fascia

Parietal tunica vaginalis

Visceral tunica vaginalis

Tunica albuginea

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26
Q

Where does the kidney form and where does it migrate to?

A

Develops in the pelvis; rises cranially taking its blood supply with it - initially from the iliac arteries, then the aorta

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27
Q

How does hypospadias develop?

A

Failure of fusion of the genital folds = persistence of the urethral groove

Varying degrees = completely open or just a narrow orifice - on the underside of the shaft

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28
Q

List of retroperitoneal organs

A

Primary

Kidneys

Ureters

Bladder

Adrenals

Aorta

IVC

Lower rectum

Secondary

D2/D3/D4

Ascending colon

Descending colon

Head and body of pancreas

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29
Q

Types of inguinal hernias and differences

Purpose and boundaries of hasselbach’s triangle

Femoral vs inguinal

A

Indirect - deep and superficial ring; direct - superficial ring only

Indirect has all 3 layers of spermatic cord

Posterior wall - direct hernias come through; inferior epigastric artery, inguinal ligament, rectus abdominis

Femoral - narrower ring - more likely to strangulate, more common in females due to wider pelvis; more likely below and lateral to pubic tubercle; more likely of the Richter type

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30
Q

Relations of quadratus lumborum

A

Anteriorly

Colon

Kidney

Subcostal, ilioinguinal and iliohypogastric lie on the fascia covering it

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31
Q

Lymphatic drainage of the pancreas

A

Nodes at the upper border of the pancres

Nodes at the medial aspect of duodenum/head of pancreas

Nodes in the root of the mesentery

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32
Q

What is the ischiarectal fossa and what are its relations?

A

Fossa between the anal canal and side wall of the pelvis

Medially - fascia over levator ani + external anal sphincter

Laterally - fascia over obturator internus

Anteriorly - deep into urogenital diaphragm

Posteriorly - limited by sacrotuberous ligaments + origin of gluteus maximus

Floor is formed from skin + subcut fat

Contains fat + nerves crossing from lateral to medial + inferior rectal vessels

Fossa communicate behind the rectum

In the lateral wall - there is a atunnel of fascia - pudendal canal (of Alcock) = contains the internal pudendal vessels and the pudendal nerve

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33
Q

Anterior and posterior relations of the stomach

A

Anterior: abdominal wall, left lobe of liver, diaphragm

Posterior: diaphragm, aorta, pancreas, spleen, left kidney and suprarenal gland, transverse mesocolon, colon - separated by lesser sac

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34
Q

What are the bony and muscular structures of the posterior abdominal wall?

A

Bony: Body of vetebrae, sacrum, wings of ilium

Muscular: Psoas major, quadratus lumborum, iliacus, posterior part of the diaphragm

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35
Q

Paramedian

Layers

A

Use is declining, 2.5cm lateral to the midline

Skin, superficial fascia, anterior rectus sheath (external + 1/2 internal oblique) + tendinous intersection (segmental vessels - so will bleed), rectus muscle, posterior rectus sheath (which only consists of transversalis fascia below the arcuate line), extraperitoneal fat, peritoneum

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36
Q

What are splenunculi?

What are their significance?

A

Accessory spleens found in the splenic mesentery

Can cause persistent symptoms following splenectomy eg thrombocytic purpura if not removed

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37
Q

Parts of the oesophagus

Start and finish

Length

A

Cervical

Thoracic

Abdominal

Lower border of the cricoid cartilage - cardiac orifice of the stomach

Approx 25cm long

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38
Q

Nerve supply of the stomach

A

Anterior (left) and posterior (right) - left is close to the anterior surface whilst right is a bit further away

Anterior gives off hepatic and pyloric branch; posterior gives off coeliac branch (for coeliac axis)

Both meet at the cardia to give off the gastric branches - travelling at the anterior and posterior part of the insertion of the lesser omentum - knwon as the anterior and posterior nerves of Latarjet

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39
Q

Route of peritoneum in the abdomen

A

Upwards and towards the right into the liver - falciform ligament

Goes in the groove between the caudate lobe and left lobe, splits into the right (upper layer of coronary ligament) and left (anteiror layer of left triangular ligament)

Ligamentum teres in the free edge

Encloses the liver - goes to porta hepatis then gastrooesophageal junction - lesser omentum

Encloses stomach - then greater curvature forms again - loops down and up to transverse colon - greater omentum

Becomes double layered again to form the transvese mesocolon - then separates - upper layer goes up to reflect onto the liver; lower layer continues onto the posterior abdominal wall

Here there are interupptions - reflection from the DJ flexure to the ileocaecal junction - forming the mesentery of the small intestine

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40
Q

Funtional anatomy of liver

A

Based on portal distribution and hepatic veins

Division is based on a line which passes through the fossa of the gallbladder and IVC - Cantlie’s line

Each lobe is then divided into 4 segments

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41
Q

Scrotum

Contents

Skin appearance

Muscle

A

Testicles via spermatic cord; left cavity longer and testicle hangs lower than right; divided by fibrous septum

Skin is thin, pigmented, rugae and numerous sebaceous glands

Subcut tissue has no fat but has dartos muscle - this is continuous with the fascia of abdominal wall and perineum - means that if there is extravasation of blood or urine deep to this layer in the abdomen it can appear in the scrotum (eg following hernia repair)

Laxity + dependent position = oedema if cardiac / renal failure

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42
Q

Third part of the duodenum

A

Longest = 10cm

Horizontal

Relations: Anteriorly: root of the mesentery + superior mesenteric vessels; posteriorly: IVC / aorta / L3 vertebra

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43
Q

Lymphatic drainage of the stomach

A

Follows arteries

Those supplied by splenic vessels - drain into the splenic hilar nodes - then the upper pancreatic nodes then to the coeliac nodes

Cardia - along the left gastric vessels - go to the coeliac nodes

Rest of the stomach - via nodes along the lesser curve - go to the coeliac nodes via common hepatic artery route; nodes along the gastroepiploic artery - to the subpyloric nodes then the coeliac nodes

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44
Q

Broad ligament structure and function

A

Fold of peritnoeum which connects the lateral body of the uterus to the pelvic wall

Contains

Broad ligament

Round ligament

Fallopian tube in its free edge

Uterine vessels and branches of the ovarian vessels

Mesovarium attaching the ovary to the posterior wall

Lymphatics

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45
Q

What structures does the mesentery contain?

A

Superior mesenteric vessels - enters the mesentery anterior to the third part of the duodenum

lymph nodes draining the small intestine

autonomic nerve fibres

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46
Q

Where is the root of the penis attached?

A

At the perineal membrane

The crura - from the ischiopubic rami

The pubic symphysis via the suspensory ligament

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47
Q

Spleen anatomy

Mesentery

A

Lies in left hypochondrium, size of clenched fist

Left lateral extremity of lesser sac

Gastrosplenic ligament - connects it to the greater curvature of the stomach - contains the short gastric and left gastroepiploic vessels

Lienorenal ligament - attaches to the posterior abdominal wall - contains the tail of the pancreas and the splenic vessels

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48
Q

Epiploic foramen relations

A

Anterior: bile duct (right) hepatic artery (left) portal vein (behind - closest to foramen)

Posterior: IVC

Superiorly: Caudate process of liver

Inferiorly: D1

At the vetebral level T12

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49
Q

Bladder anatomy

Relations: anterior, posterior, laterally, neck

A

Lies in the true pelvis, behind pubic symphysis

Anteriorly: pubic symphysis

Superiorly: peritoneum with coils of small intestine, the sigmoid colon rests above it (important in diverticulitis when colovesical fistulas can form); in females the body of the uterus

Posteriorly: rectum and seminal vesicles (males); vagina and supravaginal part of the cervix (females)

Laterally: separated from levator ani and obturator internus by loose connective tissue

Neck of the bladder: fuses with prostate (males); rests on the pelvic fascia (females)

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50
Q

Structure of the suprarenal gland

A

Comprises a cortex (mesoderm)/ medulla (ectoderm)

Medulla receives preganglionic fibres from the greater splanchnic nerve - secretes noradrenaline and adrenaline

Cortex supplies hormones (sweeter in the middle)

Zona glomerulosa (outer - mineralocorticoids)

Zona fasciculata (middle - glucocorticoids)

Zona reticularis (inner - sex hormones)

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51
Q

What is Calot’s triangle?

A

the cystic artery runs in it

Good for localising anatomy

Made up of the inferior surface of the liver, cystic duct and common hepatic duct

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52
Q

Umbilical folds of the peritoneum (below the umbilicus)

A

Median - urachus remnant

Medial - umbilical artery remnant

Lateral - inferior epigastric artery

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53
Q

Female urethra

A

Length - 4cm

Traverses the sphincter urethrae - lies in front of the vagina

Opening - 2.5cm behind the clitoris between the labia minora

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54
Q

Why is long pelvic appendix important?

A

20%

Can hang down irritate the bladder = frequent micturition

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55
Q

What abnormalities can be felt on DRE?

A

Lumen:

Faecal impaction

Foreign bodies

Wall:

Strictures

Tumours

Thrombosed haemorrhoids

Outside the wall:

Prostatic / ovarian / cervical abnormalities

Pelvic bony tumours

Masses or tenderness (due to peritonitis) in the pouch of Douglas

Foreign bodies in vagina - tampon / pessaries etc

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56
Q

What happens during left atrium enlargement for the oesophagus?

A

Displaced backwards, can be seen on barium swallow

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57
Q

Structures that form the anal canal

A

Hindgut and Proctodeum

Initially separated by the anal membrane - which is formed when the urogenital septum reaches the cloacal membrane

(proctodeum - invagination of ectoderm)

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58
Q

Parts of the ureter and relations: anterior/posterior

A

Abdominal

Anterior: peritoneum, colic vessels, ovarian/testicular vessels, ileum/mesentery (R) OR sigmoid/mesentery (L)

Posterior: psoas major ± minor, genitofemoral nerve, bifurcation of common iliac

R = close to the lateral border of the IVC

Pelvic

Crosses bifuracation, crosses obturator nerve + anterior branches of internal iliac, goes to the ischial spine, turns medially on to base of bladder

then below vas deferens (M) OR past the lateral fornix of the vagina below the uterine artery

Then enters the base of the bladder

Intravesical

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59
Q

Anatomy of the anal canal

A

4cm long; separated from upper and lower by dentate line

Mid canal = vertical column in mucosa = columns of morgagni

Distal end = valve like folds (valves of Ball), behind are the sinuses into which the anal glands open into

Upper= columnar epithelium; lower = squamous epithelium, becomes skin at the anal verge

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60
Q

Pancreas

Parts

Which plane does it lie in?

How do you work out this plane?

What level is this plane in?

A

Head, uncinate process, neck, body, tail

Transpyloric plane

Midpoint between suprasternal notch and pubic symphysis

L1/9th costal cartilage

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61
Q

Peritoneal cavity:

Layers of peritoneum

Cavities

Lined by?

A

Parietal (abdominal and pelvic wall); visceral (organs)

Greater and lesser sac

Mesothelium (simple squamous epitherlium)

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62
Q

Blood supply

A

From splenic artery via arteria pancreatica magna

Head and uncinate process - superior pancreaticoduodenal artery (anterior/posterior) - branch of gastroduodenal artery

and

inferior pancreaticoduodenal artery (anterior/posterior) - branch of superior mesenteric artery - they anastomose

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63
Q

Nerve supply

Rectus abdominis

External oblique

Internal oblique

Transversus abdominis

A

Thoracoabdominal (T7-11)

Thoracoabdominal (T7-11) + subcostal (T12)

Thoracoabdominal (T7-11) + subcostal (T12) + lumbar plexus branches (iliohypogastric and ilioinguinal)

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64
Q

Structure of oesophagus

A

Mucosa - stratified squamous epithelium

Submucosa - mucous glands

Inner muscle - circular

Outer muscle - longitudinal

[Upper 1/3 muscle is striated - for rapid swallowing; lower 2/3 is smooth for peristalsis]

Outer layer loose areolar tissue

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65
Q

Mesentery of small intestine

A

Free edge is where jejunum and ileum are

Approx 15cm long - from DJ flexure left of L2 to right sacroiliac joint

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66
Q

Lobes of the prostate

A

Posterior: posterior to the urethra, on the plane below the course of the ejaculatory ducts

Median: between the ejaculatory ducts and posterior to the urethra

Lateral: lobes separated by a shallow median groove on the posterior surface (felt on a rectal examination)

Anterior: only an isthmus present consisting of a fibromuscular tissue

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67
Q

Relations of the prostate

Anterior

Posterior

Superior

Inferior

Laterally

A

Anteriorly: symphysis pubis; with a layer of extraperitoneal fat in front (cave of Retzius)

Posteriorly: erctum, separated by fascia of denonvilliers

Superiorly: continuous with neck of the bladder

Inferiorly: apex of prostate rests on external urethral spinchter in the deep perineal fascia

Laterally: levator ani

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68
Q

Corpora cavernosa

A

Dorsally located, connected together in the anterior three quarters with septum intervening; fits into the base of the glans

Separate behind to form the two crura

2 groovees - lower surface - dorsal vein of peins; upper suface - corpus spongiosum

Attached to pubic symphysis via suspensory ligament

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69
Q

Anal sphincters

and innervation

A

Internal anal sphincter - conntinuous with the circular muscle of the rectum; covers u[pper 2/3 of anal canal)

External anal sphincter - starts lower down and extends further distally; deep, superficial, subcutaneous; deep is blended with levator ani muscle

Anorectal ring is the deep part of external sphincter (where it blends with levator ani) + internal sphincter = can be palpated on rectal examination

Subcutaneous is traversed by fan shaped structure = continuation of the longitudinal muscle fibres of anal canal

Innervation - S2,3,4

S2,3 - pudendal nerve + inferior rectal nerve

S4 - perineal branch

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70
Q

Ascending colon

A

From caecum to posterior aspect of liver - turns sharply at hepatic flexure

Covered on anterior and lateral surface with peritoneum

Posterior relations: iliacus, quadratus lumborum and perirenal fascia over the lateral aspect of the kidney

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71
Q

Ureter in relation to the broad ligament

A

Ureter passes along the border of the broad ligament

Then passes lateral to and then immediately above the lateral fornix of the vagina

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72
Q

Relations of the gallbladder

A

Duodenum

Transverse colon

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73
Q

Formation of the bladder

A

Proximal part of the allantois (apex of bladder - urachus)

Vesicourethral part of the urogenital sinus (body of the bladder and prostatic portion)

Caudal ends of the mesonephric ducts (trigone and dorsal wall)

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74
Q

Hepatic veins anatomy

A

3 hepatic veins: right, middle and left

Right in right portal fissure, drains 5, 6, 7, 8

Middle in main portal fissure (same plane as IVC), drains 4A, 4B, 5, 8

Left in left portal fissure, drains 4B, 2, 3

Divide liver into 4 sectors: right lateral (6,7), right medial (5,8), left medial (3,4), left lateral (2) - each supplied by one portal pedicle

Caudate lobe is segment 1 - but has its owm supply, and produces smaller hepatic veins

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75
Q

Inguinal canal location

A

Starts at the deep ring (1cm above the midpoint of the inguinal ligament - ASIS - PT); ends at the superficial ring (located medial and above the pubic tubercle)

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76
Q

Location of the superficial ring

A

V shaped defect in the inguinal ligament

Above and medial to the PT

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77
Q

Anatomy of the gallbladder

A

Posterior surface of liver - whose fossa divides the left and right lobe of the liver

50mL of bile when full - store and concentrates bile

Fundus, body and neck - which opens into the cystic duct

Ventral surface - Hartmann’s pouch where a stone can get lodged

Cystic duct lumen = spiral mucosal valves of Heister - make it difficult endoscopically

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78
Q

Appendices epiploicae

What are they?

Where are they found?

Where are they not found?

A

Fat filled tags, found on the surface of the colon

Not found on the caecum, appendix or rectum

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79
Q

Rectus abdominis

Origin

Insertion

Where and how many are the tendinous intersections?

Where do they adhere to?

A

pubic crest

5, 6, 7 costal cartilages

3 - xiphoid, umbilicus, halfway between the two

Anterior sheath only (not posterior)

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80
Q

Parts of the male urethra

A

Prostatic

Membranous

(Bulbar)

Spongy

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81
Q

Midgut development

A

Pushed out into the umbilical cord as the contents grow rapidly

Sucked back in around the 10th week as the cavity expands

Continues to rotate at to the left 180 degrees - bringing the ascending colon to the right side and the caecum just below it

caecum moves down even further to get fixed in the RIF

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82
Q

Portal system

A

Drains blood from the abdominal oesophagus, spleen, pancreas, gallbladder

Superior mesenteric vein joins the splenic veins behind the neck of the pancreas = forming the portal vein which travels in the free edge of lesser omentum

Inferior mesenteric vein joins the splenic vein behind the body of pancreas

Poral vein splits into right and left hepatic vein which then supplies the 4 functional lobules of the liver

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83
Q

Lympahtics of the uterus

A

Fundus:

along ovarian vessels to para-aortic nodes

via vessels in the round ligament to inguinal nodes [mets from fundus can go to the inguinal nodes]

Body

via broad ligament to iliac nodes

Cervix

laterally via the braod ligament to external iliac nodes

posteriorly via uterosacral ligament to the presacral nodes

posterolaterally via the uterine vessels to the interal iliac nodes

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84
Q

Route of the peritoneum in the pelvic cavity

A

Umbilical folds

Rectum - upper 1/3 (front and sides); middle third (front)

Bladder - reflected onto base and upper part (males); reflected onto posterior vaginal wall, then posterior, upper and anterior surface of uterus and onto base of bladder (females) – pouch of douglas forms in the rectouterine space; also goes laterally from the uterus onto the fallopian tubes - forming broad ligaments

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85
Q

Fourth part of the duodenum

A

Ascends vertically to end, then turns anteriorly left abruptly to form jejunum

2.5cm

DJ flexure - by moving anteirorly it leaves the posterior abdominal wall and acquires a mesentery

DJ flexure suspended by suspensory ligament of Treitz from the right crus of diaphragm to termination of duodenum

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86
Q

Epididymis in relation to testes

A

Along the posterior border (lateral side)

Median edge has a groove = the sinus epididymis

Covered by tunical vaginalis - but posterior edge free

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87
Q

Transversus abdominis

Origin

Insertion

A

Deep surface of lower 6 costal cartilages (interdigitating with diaphragm), anterior 2/3 iliac crest, lateral 1/3 of inguinal ligament, lumbar fascia

Linea alba, pubic crest via conjoint tendon

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88
Q

Blood supply of the oesophagus in the areas:

cervical

thoracic

abdominal

A

Cervical

Artererial: inferior thyroid artery

Venous: inferior thyroid vein

Thoracic

Arterial: branches of the aorta

Venous: azygos veins

Abdominal:

Arterial: inferior phrenic artery + left gastric artery

Venous: left gastric vein (portal) + azygos veins (systemic)

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89
Q

Portal hypertension

A

No valves = so any increase in pressure is seen across the system = anastomosis sites most vulnerable = dilate and bleed

Sites of anastomosis

Oesophagus (haematemesis) = oesophageal branch of left gastric vein (portal) –> oesophageal tributaries of the azygos system (systemic)

Rectum (bleeding) = superior rectal branch of inferior mesenteric vein (portal) –> inferior rectal vein (systemic)

Mesentery (retroperitoneal bleeding) = portal veins in the mesentery (portal) –> retroperitoneal veins (systemic)

Anterior abdominal wall (caput medusae) = portal veins in the liver (portal) –> veins of the abdominal wall (systemic) via veins on the falciform ligament

Portal branches in the liver –> veins of the diaphragm (systemic) related to bare area of the liver

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90
Q

Midline Incision

Benefits (x3)

Structures encountered

A

Through linea alba skirting the umbilicus

Rapid access + minimal blood loss

Skin, subcutaneous fat, superficial fascia (two layers in lower abdomen - scarpas only below the level of umbilicus), linea alba, extraperitoneal fat, peritoneum

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91
Q

Ovary anatomy

A

Size of almond

In the posterior aspect of the broad ligament - connected to the pelvic wall via mesovarium

Suspensory ligament connected - travels over the pelvic brim and external iliac vessels - merges with peritoneum over psoas major - ovarian artery travels through this

Ovarian ligament = connects ovary to the cornu of the uterus, runs within the broad ligament

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92
Q

Internal iliac artery route

A

Travels backwards and downwards between ureter anteriorly and internal iliac vein posteriorly

Divides into anterior (superior gluteal) and posterior (inferior gluteal / obturator) branch at the upper border of greater sciatic foramen

Supplies pelvic organs, perineum, buttock, anal canal

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93
Q

Variations of extrahepatic ducts

A

Cystic duct joins much lower down - behind the duodenum

Cystic duct virtually absent = gallbladder opens directly into common hepatic duct

Cystic duct opens into the right hepatic duct

Accessory hepatic ducts open into the gallbladder/cystic duct

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94
Q

Blood supply of the uterus

A

Uterine artery (branch of the internal iliac artery)

travels in the base of the broad ligament

2cm lateral to the cervix - passes superiorly and anteriorly - entering the uterus at the internal os

Travels up the body of the uterus in a tortuous manner

Goes laterally and inferiorly to the fallopian tube - terminates by anastomosing with the terminal branches of ovarian artery

Uterine artery - gives off descending branch to the vagina and cervix

Uterine veins accompany the artery - draining to the internal iliac vein

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95
Q

How is malrotation caused?

Where does the first part fix?

Where does the second part fix?

What happens if they both don’t fix?

A

Incomplete development of the midgut - the DJ flexure fails to be fixed retroperitoneally (anchored to the SMA via lig of Treitz) - hangs freely from the foregut to the right of the abdomen

OR the caecum is not fixed in the RIF (goes to RUQ) - can cause small bowel obstruction due to the peritoneal bands (of Ladd) that run across it and fix to the abdominal wall there

If both = whole midgut not fixed - can twist on its blood supply (SMA) = volvulus neonatorum

96
Q

Development of the testes

A

Develops on the posterior abdominal wall - which assocaites with its blood supply, nerves and lymphatic drainage

Descends into the inguinal canal and exits at the superfiical ring into the scrotum

97
Q

Importance of the anastamoses in the distal oesophagus

A

Portosystemic anastomoses - oesophageal tributary of the left gastric vein (portal) with azygos vein (systemic)

Can results in oesophageal varices in portal hypertension

98
Q

Incorrect formation of the foregut causes?

A

Oesophageal atresia (8%)

Tracheo-oesophageal fistula (80%) - lower part of the trachea fuses with the distal oesophagus

99
Q

First part of the duodenum

Direction

Relevance of first 2-3cm for peritoneum

Relations: anteriorly and posteriorly

A

Superiorly and posteriorly

Total 5cm, first 2-3cm has got visceral peritoneum (it is intraperitoneal)

Anterior relations: liver / gall bladder

Posterior relations: portal vein, common bile duct, gastroduodenal artery; behind this is IVC

100
Q

Why is the attachment of Scarpa’s fascia to the thigh fascia important clinically?

A

Rupture of bulbous urethra - urine tracks into penis, scrotum and abdominal wall but not into the thigh

Ectopic testis cannot descend any lower into thigh

101
Q

Duodenum: shape; length (for each part)

A

C shaped, 25cm: 5, 7.5, 10, 2.5cm

102
Q

Seminal veiscles

Location

Anatomy

A

Lie on each side in the interval between the bladder and the rectum

Lateral to the vas

Common duct with the vas - common ejaculatory duct

Usually impalpable but if TB / other infection - can be palpable

103
Q

Causes of the different subphrenic abcessess

A

Subphrenic - perf peptic ulcers, appendicitis, diverticulitis

Subhepatic - right - tacks up the right paracolic gutter into the right subhepatic space - when patient is recumbent

Subhepatic - left - in the lesser sac from perforated posterior gastric ulcer / acute pancreatitis (pseudocyst)

Usually drained percuaneously (image guided) or if surgery is required - posterior (below/through the bed of 12th rib) or anterior (below and parallel to costal margin)

104
Q

Lumbar sympathetic chain route

A

Starts deep to the medial arcuate ligament (as a continuation of the thoracic chain)

Lies in front of the lumbar vertebrae overlapped by IVC on right and aorta on left

Lumbar arteries are deep, lumbar veins superficial

Continue deep to the iliac vessels to reach the sacrum where it becomes the sacral trunk

Converge in front of the coccyx to form the ganglion impar

105
Q

Membranous urethra

A

2cm in length

Between the perineal membrane and pelvic fascia

Pierces the enternal urethral sphincter

106
Q

How are retroperitoneal organs attached?

A

Adeventitia - dense fibrous irregular connective tissue

107
Q

Large intestine

Length

Parts

A

1.5m

Caecum with vermiform appendix

Ascending colon (hepatic flexure)

Transverse colon (splenic flexure)

Descending colon

Sigmoid

Rectum

Anal canal

108
Q

Hydrocele - formation and types

A

Failure or partial obliteration of the processus vaginalis

Can be congenital (whole), vaginal (only of the scrotum) or cord

109
Q

Blood supply of the ureters

A

Renal arteries

Testicular/ovarian artery

Internal iliac

Inferior vesical arteries

110
Q

Corpus spongiosum

arises?

surrounded by?

ends up as what?

in the middle of it?

A

Arises from bulb (below perineal membrane)

surrounded by bulbospongiosus muscle

in the undersurface of corpora cavernosa - then over their extremities to form the glans

urethra in the middle

111
Q

Contents of femoral canal

A

Cloquet’s lymph nodes

Fat

Lymphatics

112
Q

Vulva - definition and components

A

External genitalia

Parts: mon pubis (fat over the pubic symphysis);

labia majora (over mon pubis; externally - hair and skin; internally mucous membrane)

labia minora - posteriorly - meet at the fourchette; anteriorly - surround the clitoris: upper side forming the prepuce, lower attaching to the glans via the frenulum

vestibule - area enclosed by minora - contain urethral orifice and vaginal orifice (hymen here naturally - after childbirth on remnants known as carunculae

greater vestibular glands (bartholins - open deep to the labia majora posteriorly external to the hymen; similar to bulbourethral glands in males); they are overlapped by the bulb of the vestibule (similar to erectile tissue) - covered in bulbospongiosus travel to the clitoris

clitoris - two corpa cavernosa - attach to ischiopubic rami; free extremity formed by corpus spongiosum

113
Q

Development of the anal canal

A

9th week - structures separate within the cloaca

Urorectal septum divides the cloaca into the bladder and rectum (hindgut); reaches the caudal end - which is the cloacal membrane

Forms the anal membrane and urogenital membrane

Anal membrane separates the hindgut from the anal pit (formed from the invagination of the ectoderm known as proctodeum)

Loss of membrane = continuity between hindgut and anal pit = anal canal

114
Q

Anatomy of the kidney

Location

Relations

Layers and what are they continuous with

A

R lower than L due to liver; between T12 and L3 with the renal vessels at L1

Sit beneathe costal margin, protected by 11th /12th ribs

Anterior:

R - hepatic, duodenal, colic areas, suprarenal

L - gastric, splenic, pancreatic, jejunal, colic areas, suprarenal

Posterior (medial to lateral):

Psoas major

Quadratus lumborum

Transversus abdominis

Layers (Deep to superficial)

Fibrous capsule

Perinephric fat

Fascia (continuous anteriorly - diaphragm [separating it from suprarenal gland = easily separable], medially aortic/IVC sheath, laterally transversalis fascia, inferiorly open)

115
Q

Subphrenic spaces

A

4 - can be the point of subphrenic abcesses

Right and left suphrenic spaces (found either side of the falciform ligament between the liver and the diaphragm)

Right subhepatic space (renal well of Rutherford Morrison)

Left subhepatic space (lesser sac)

116
Q

Boundaries of the right subhepatic space

A

Above: liver attached to gallbladder

Behind: posterior abdominal wall and kidney

Below: duodenum

117
Q

External iliac artery route

A

Runs along the pelvic brim, along the medial border of psoas major

Goes beneath the inguinal ligament to become the femoral artery

Just before the inguinal ligament it gives off the inferior epigastric artery

118
Q

Dimensions of testis

A

4cm superior to inferior

3cm AP

2.5cm medial to laterla

119
Q

Clinical points of arteries of the stomach

A

Ulcer on the lesser curve - erodes into right or left gastric arteries = haematemesis / malaena

Ulcer / carcinoma on the posterior surface of the stomach = erode into the pancreas = pain radiating to the back

120
Q

Anterior triangle borders and structures

A

Triangle formed by the inferior ischiopubic rami and line joining the ischial tuberosities

Middle of triangle = perineal membrane - strong sheath pierced by urethra (males) or urether+ vagina (females)

Deep to this is deep perineal pouch which contains the external urethral sphincter - striated muscle surrounding the membranous urethra; other contents are the bulbourethral glands - whose ducts pierce the membrane and form the bulbous urethra; also contains deep transverse perineal muscles

Above this - superior fascia of urogenital diaphragm (technically the perineal membrane is the inferior fascia)

Superior = superficial perineal pouch

121
Q

Blood supply of the bladder + venous drainage

Lymphatic drainage

A

Superior and inferior vesical arteries - branches of the internal iliac arteries

Rich venous plexus around the bladder: draining into the internal iliac veins

Drain along the vesical vessels to the internal iliac nodes which drains into the para-aortic nodes

122
Q

Relations of psoas major

A

Lumbar plexus in between superficial and deep layers

Structures on it - ureters, gonadal vessels, IVC

Psoas sheath - encloses it and is beneath the inguinal ligament (means if there is infection of the lumbar vertebrae eg TTB - pus can spread down below inguinal ligament and present as an abcess)

Tendon lies in front of the hip joint with the bursa intervening and is directly behind the femoral artery (which can be palpated)

Retrocaecal / retrocolic appendix lying anteriorly (if appendicitis can cause psoas sign)

123
Q

Important relations between right and left common iliac arteries

A

Right common iliac artery

Right common iliac vein is just behind and to the right

Left common illiac vein crosses behind it

SMA crosses it anteriorly

Left common iliac artery

left common iliac vein is below and medial to it

IMA crosses it anteriorly

124
Q

Cervical oesophagus - route and relations - anterior/posterior/left/right

A

Route: downwards and slightly left

Relations

Anterior: trachea, thyroid

Posterior: lower cervical vetebrae, prevertebral fascia

Left: Left common carotid, left inferior thyroid, left subclavian arteries, thoracic duct, left RLN in the groove

Right: right common carotid, right RLN in the groove

125
Q

What is epispadias?

What is a serious complication?

A

Dorsal wall of uretha partially / completely absent = failure of infraumbilical mesodermal development (or abnormal migration of genital tubercle caudally instead of cranially)

Ectopia vesica - ureteric openings and trione of the bladder is on the abdominal wall associated with cleft pelvis (no symphysis pubis)

126
Q

Prostate

Structure in relation to the urethra

A

Glandular tissue

Smooth muscle (about 25%)

Mostly lies posterior and laterally to the urethra, little anteriorly

127
Q

Uterus dimensions

A

7cm long, 5cm side to side, 3cm AP

Pear shaped

Fallopian tubes enter @ supralateral angle

128
Q

Blood supply of the testes

A

Arterial - testicular artery (from aorta at level of renal arteries) which anastomoses with the artery of the vas (from the inferior vesical branch of the internal iliac artery) [if you ligate testicular artery its ok]

Venous - pampiniform plexus of the veins - which converge to a singe testicular vein at the deep ring

Right - IVC; left - left renal vein

129
Q

Consequence of anal membrane failing to rupture / anal pit failing to develop

A

Imperforate anus

130
Q

How is malrotation treated?

A

Mostly small bowel obstruction due to bands of Ladd

Ladd’s procedure is done

  • de-torsion
  • resection of necrosed bowl
  • division of ladd’s bands
  • expansion of mesenteric base - by placing caecum on left and small bowel on right
  • appendectomy
131
Q

Gridiron incision (muscle splitting)

Use + Process

Structures

A

Appendectomy

Centred on mcburney’s point - 2/3 from umbilicus to ASIS

Skin, campers’, scarpa’s (more towards lower end of incision), external oblique (the aponeurosis), internal oblique, transversus, extraperitoneal fat, peritoneum

132
Q

Superficial perineal pouch contents (male vs female)

A

Bulb of penis (attached to perineal membrane): corpus spongiosum surrounded by bulbospongiosus

Crura of penis (attached to the angle between perineal membrane insertion and ischiopubic rami): surrounded by ischiocavernosus

Superficial transverse peroneal muscle

Female is same but less well developed; also has bulb of vestibule (for bulb of penis) and bartholin’s glands present

133
Q

Abdominal aorta location

A

Infront of T12 to front and left of L4 - then divides into common iliacs

134
Q

Structure of the gastric mucosa

A

Surface is composed of columnar epithelial cells secreting mucous and alkaline fluid (necessary to protect the stomach from acid)

3 areas:

Cardiac gland area via GO junction - mucus

Oxyntic gland area (acid-secreting) - parietal (oxyntic) and chief (zymogen)

Pyloric end area (distal 30%) - gastrin from G cells and mucous

135
Q

Anal cushions

Location

Purpose

A

Located at 3, 7 and 11 o’clock

In upper half

important for continence, air tightness and mucus production

136
Q

Blood supply of the gallbladder

A

Via the cystic artery - a branch of the right hepatic artery (can also be direct from the main hepatic artery)

usually crosses behind the common bile duct and hepatic artery to reach the upper surface of the neck of the gallbladder

Lies in Calot’s triangle

Also gets arterial supply from the liver bed - no gangrene if cystic artery thrombosed

Venous drainage - small veins directly into the bed of the liver

137
Q

Branches of the aorta

Anterior unpaired (3)

Lateral paired (3)

Paired branches to the parieties (2)

Terminal brances (2)

A

Anterior Unpaired

Coeliac trunk (left gastric, common hepatic, splenic)

SMA

IMA

Lateral paired

suprarenal artery

renal artery

gonadal artery

Paired parieties

inferior phrenic artery

four lumbar arteries

Terminal branches

Common illiacs

Median sacral artery

138
Q

Abdominal oesophagus - route

Relations: a

A

Oesophageal opening in the right crus at T10; then lies in the groove on the posterior surface of the left lobe of the liver with the left crus posteriorly

Covered anteriorly and to the left with peritoneum, anterior vagus behind peritoneum, posterior vagus is further away from the posterior wall of the oesophagus

139
Q

Posterior triangle borders and contents

A

Ischial tuberosities and coccyx

Contents:

levator ani

anal sphincters

ischiorectal fossa

140
Q

Inferior vena cava

At what level is it formed?

What separates it from the aorta at the diaphragm?

What level does it pass the diaphragm?

A

L5 - from left and right common iliac vein, behind the right common iliac artery

Right crus of diahragm

T8

141
Q

Fallopian tubes

Anatomy

Parts

A

Fallopian / uterine tubes - 10-12cm long - run from lateral side of the body of the uterus to the pelvic wall - end near the opening of the ovary

Infundibulum - fimbrae to collect egg

Ampulla - wide, thin walled, tortuous

Isthmus - thick walled, straight, narrow

Intramural part - no peritoneum; peritoneum over the rest like a drape

Fertilised ovum - can implant anywhere - most likely ampulla = ectopic - can rupture and bleed = intraperitoneal haemorrahe

142
Q

Spongy urethra

A

15cm

Passes below the pubic symphysis (esp on erection - which means trauma to pubic symphysis can rupture the urethra)

Bulbourethral glands open on its floor

Just before the external meatus - there is the fossa navicularis - widening of the urethra

Mostly transverse but vertical at meatus = spiral stream of urine

143
Q

Functions of femoral canal

A

Dead space for expansion of femoral vein

pathway of lymphatics from lower limb to external iliac nodes

144
Q

Posterior relations of the IVC

A

Vertebral column

Right renal artery

Right suprarenal artery

Right suprarenal gland

Right inferior phrenic artery

Right lumbar arteries

Right sympathetic trunk

Right crus of diaphragm and psoas major

To the left: aorta

145
Q

Formation of the urethra in males

A

Urethra above the prostatic utricle - from the vesicourethral part of cloaca AND incorpporated ends of the mesonephric duct

Urethra below the prostatic utricle (prostatic and membranous urethra) - from the urogenital sinus

Urethra and glans - genital (urethral) folds encompassing the phallic portion of the urogenital sinus

146
Q
A
147
Q

What happens during foregut rotation?

A

Rotates clockwise

Liver attaches to the stomach - lesser omentum (ventral mesogastrium); stomach attaches vai the spleen to the posterior wall - greater omentum (dorsal mesogastrium)

Rotation means - stomach swings to the left - right wall of the stomach becomes posterior surface - behind it is the lesser sac

The vagus nerve - Right becomes posterior; left becomes anterior

Duodenum swings to the left - so far the its mesentery fuses with the posterior abdominal wall - becomes retroperitoneal apart from D1

148
Q

Pararectal incision

A

Lateral border of the rectus below the level of the umbilicus

Can be used for appendicectomy; more commonoly for peritoneal dialysis (tenchkoff catheters)

RISK: extending the incision, can damage the nerves supplying the rectus - causing wasting + predisposition to hernias

149
Q

Anterior relations of the IVC

A

Mesentery

Third part of duodenum

Pancreas

First part of duodenum

Portal vein

Posterior surface of liver

Diaphragm

Arteries from above down: hepatic, right testicular, right colic, right common iliac

150
Q

Meckel’s diverticulum remnant of the duct importance

A

Can act as a fixed point for the small bowel volvulus

151
Q

Arterial supply of the stomach

A

Coeliac trunk - giving off left gastric, common hepatic, splenic

Left gastric - lesser curvature of the stomach; anastomoses with the right gastric

Common hepatic - hepatic artery proper, right gastric, and gastroguodenal artery (important as posterior side of duodenum) - becomes the right gastroepiploic artery

Splenic - gives of the short gastric (supplies fundus) and left gastroepiploic supplying the greater curvature (anastomoses with right gastroepiploic)

Gastroduodenal before forming the R gastroepiploic gives off the posterior and anterior superior pancreaticoduodenal artery - which anastomoses with the equivalent inferior PD artery from the SMA; also gives off the supraduodenal supplying its namesake

152
Q

Relation of the pancreas to the superior mesenteric vessels

A

Head is in the C of the duodenum; attached to the medial border - superior mesenteric vessels run behind it

Neck - posteriorly where the splenic veins meets the superior mesenteric vein to form the portal vein

Body is where the inferior mesenteric vein joins the splenic vein

Tail is in the splenic hilum

Superior mesenteric vessels run in front of the uncinate process

Common bile duct passes in a groove behind the head of the pancreas

153
Q

Parts of the glans

A

External urethral meatus

The corona - edge

The frenulum - fold of mucus membrane attached to the prepuce

Skin of the penis attached to the neck of the glans - foreskin

154
Q

Surfaces of the liver

A

Superior: dome shaped, related to diaphragm

Posteroinferior: covered with peritoneum (not the gallbladder and porta hepatis and ligamentum venosum); related to the stomach, duodenum, oesophagus, hepatic flexure, right kidney, right suprarenal gland

Posterior: connected to the diaphragm by the coronary ligament, in the middle of which is the bare area

RIght and left lobes are sepated by falciform ligament anteriorly, and the H shapped arrangement posteriorly

H shape:

L - ligamentum venosum, ligamentum teres

R - IVC and gallbladder

Middle - caudate and quadrate - separated by porta hepatis

155
Q

Sections of the cloaca

A

Cephallic - vesicourethral (above the entrance of the mesonephric duct)

Middle - phallic

Lower - pelvic

156
Q

Differences between upper and lower half of anal canal

Surface

Development

Innervation

Lymph

Venous

A

Surface

Columnar epithelium in upper, squamous in lower: can form adenocarcinoma in upper, squamous cell carcinoma in lower

Development

Upper from endoderm, lower from ectoderm

Innervation

Upper from autonomic - not sensitive to pinprick (important when injecting for haemorrhoids), lower from inferior rectal nerve - sensitive to pin prick

Lymph drainage

Upper drains to superior rectal nodes to inferior mesenteric nodes, and also laterally internal iliac nodes

Lower drains into inguinal nodes primarily - carcinoma here can metastasise to the inguinal nodes

Venous drainage

Upper drains into the portal system, lower drains into the systemic circulation = site of portosystemic anastomses, can be affected in portal hypertension

157
Q

What structures do the root of the mesentery cross?

A

D3

aorta

IVC

right psoas major

right ureter

right gonadal vessels

right iliacus

158
Q

Vagina

A

Muscular tube - approax 7cm long

Cervix projects inwards, vagina surrounds it - with anterior, posterior and lateral fornices

Opens into the vestibule

159
Q

Caecum features

A

Blind ended pouch, with appendix located posteromedially; 2.5cm below ileocaecal valve

Completely covered by peritoneum

160
Q

Muscles of the abdominal wall

A

Rectus abdominis

External oblique

Internal oblique

Transversus abdominis

161
Q

What are the taenia coli?

A

Longitudinal bands of muscle that start at the caecum and end at the recto-sigmoid - converge at the base of the appendix

Shorter than the length of the colon - which causes the characteristic bulges along the colon

Help with peristalsis

No tenia coli on appendix or recturm

162
Q

Left triangular ligament significance?

A

Formed from left peritoneal covering from falciform ligament

Attaches to the lesser omentum in the fissure of ligamentum venosum

No major blood vessels = can be divided safely to retract the left lobe of the liver to expose the oesophagus

163
Q

Difference between omphalocele and gastrochisis

A

Omphalocele - bowel covered by peritoneal membrane; failure to retract from the cord

Gastrochisis at the 10th week - herniation without any membrane; likely due to a defect in the membrane

164
Q

Formation of the urethra in females

A

From the vesicourethral section of the cloaca

165
Q

Surgical approach for a kidney excision

A

Oblique incision = helfway between 12th rib and iliac crest - extending from lateral border of erector spinae to lateral border of rectus abdominis

Latissimus dorsi + seratus posterior inferior divided

Free edge of external oblique divided

Internal oblique + transversus abdominis divided [reveals peritoneum]

Peritoneum pushed forwards, renal fascial capsule is opened

Subcostal nerve + vessels are left intact

If more room is required: incision extended = quadratus lumborum edge is incised + lateral border of 12th rib excised

Must be careful about medial portion of 12th rib as pleura descends below it

166
Q

Anatomy of testes (not epididymis)

A

Covered by white fibrous capsure - tunica albuginea

Over this the tunica vaginalis testes (double layered - parietal and visceral - with a cavity at the top of the testes between the two)

Inside lobules separated by a septum (septa testes - originates from tunica albuginea) - each with 1-3 coils of semineferous ducts - sperm produced here

These drain into rete testes (at the hilum - afferent to drain into head of epididymis)

167
Q

Psoas major

Origin

Insertion

Nerve supply

Action

A

Deep: Transverse processes of L1-L5; superficial: bodies and discs of T12-L4

Lesser trochanter

L2, L3 (of lumbar plexus between layers of psoas major)

Flexion and medial rotation of extended thigh; unilateral causes lateral flexion

168
Q

What is the urogenital sinus?

A

Made up by two parts of the cloaca - the phallic and pelvic part (middle and caudal)

Formed from the urogenital septum fusing with the cloacal membrane - forming the anal canal and the urogenital sinus

169
Q

Blood supply of the prostate

A

Via the inferior vesical artery - branch of the internal iliac artery

Venous via the prostatic venous plexus which drains into the internal iliac vein

Some venous blood drains posteriorly: into the vertebral veins of Batson - which is why prostate carcinoma can easily spreadto the bones of the lumbar spine

170
Q

Lymphatic drainage of the vagina

A

Upper 1/3 = internal and external iliac nodes

Lower 2/3 = superficial inguinal nodes

171
Q

Descending colon features and relations

A

Splenic flexure to left iliac fossa for sigmoid colon

peritoneum covers its anterior and lateral surface

between the diaphragm and descending colon = phrenicocolic ligament

Relations: posteriorly: left kidney, iliacus, quadratus lumborum

anteriorly: small intestine

172
Q

Common iliac artery

Where it starts and bifurcates

What are the 4 anterior relations?

A

Starts L4; bifurcates at the sacroiliac joint level

Peritoneum, ureters, small intestine, sympathetic nervous system

173
Q

What are the superficial fascia on the anterior abdominal wall?

A

Camper’s - fatty

Scarpa’s - membranous / fibrous (thinner) - extends into the perineum as Colle’s; attaches with the thigh fascia lata (2.5cm below inguinal ligament)

Scarpa’s goes into the penis and scrotum as dartos

174
Q

Extrahepatic biliary system

A

Right and left hepatic duct join at the porta hepatis to form the common hepatic dut

Cystic duct joins to form the common bile duct

starts approx 4cm above the duodenum, travels behind it then on the posterior surface of the head of the pancreas in the groove

Joins with the pancreatic duct to become the ampulla of Vater, controlled by the sphincter of Oddi - opens in D2

Sometimes - can open separately - accessory pancreatic duct - which opens 2cm proximal on the medial surface of the second part of the duodenum

175
Q

Rectum

Length

Route

Peritoneal coverings

Lateral inflexions

A

approx 12 cm

starts at the distal 1/3 of the sacrum and ends 2.5cm away from the coccyx; where it bends sharply backwards to become the anal canal

Peritoneum:

Upper 1/3 - front and sides

Middle 1/3 - front

Lower 1/3 - none (is completely extraperitoneal, below the pelvic peritoneum

3 lateral inflexions; left right left where it has valves of houston at each inflexion

176
Q

Cystocopy

Purpose

Findings of the mucosa/submucosa

Findings of the mucosa/submucosa in the trigone

Ridge between ureters?

A

Examine the internal meatus and the two ureteric orifices

Loosely adherent to overlying muscle wall, so arranged in folds when empty

Mucosa smooth

Interureteric ridge

177
Q

Where does the glans of the penis develop from?

What develops from the glans?

A

From the genital tubercle

Terminal part of the urethra develops from the glans

178
Q

Blood supply of the ovary

A

Artery - ovarian artery, branch of the aorta arising from the level of renal arteries

Veins - right drains into IVC, left into left renal vein

Lymphatic - follows ovarian arteries to para-aortic nodes

179
Q

Levator ani muscles

Types

Origin

Insertion

Nerve supply

Action

A

Ilicoccygeus, Puborectalis, Pubococcygeus (the medial fibres for the levator prostatae aka puboprostatus / pubovaginalis)

Posterior of pubic body, tendinous arch of the obturator fascia (which runs from pubic body to ischial spine)

Forms a sling around the prostate/vagina (pubococcygeus) and rectum (pubovaginalis); into the sides of the coccyx and the median raphe

Perineal branch of S4 on pelvic surface; branch of inferior rectal and perineal division of the pudendal nerve on the perineal surface

Support of pelvic floor, supports abdominal viscera during raised IAP, controls sphincter action on the rectum and vagina, assists in increasing IAP during defecation, micturition and parturition

180
Q

Relations of the inguinal canal

A

Anteriorly - skin, campers, scarpas, external oblique aponeurosis internal oblique for lateral 1/3

Posteriorly - Medially - conjoint tendon (aponeurosis of internal oblique and transversus); laterally - transversalis fascia

Superiorly - lower arching fibres of internal oblique and transversus abdominis

Inferiorly - inguinal ligament (recurved edge of external oblique)

181
Q

What structures lie on the posterior wall of the abdomen?

A

Aorta

IVC

Kidneys

Adrenals

Lumbar sympathetic chain

182
Q

Relations of the ovary (it can be very variable)

A

Lies along the pelvic wall - in a hall fossa - whose floor is the fascia of obturator internus (with obturator nerve close by)

Anteriorly: external iliac vessels

Posteriorly: ureter and internal iliac vessels

183
Q

Structure of pancreas

A

Surround by fibrous capsule, whose septae divide the pancreas into lobules

Lobules consist of acini of serous cells - secrete pancreatic enzymes into ducts lined with cuboidal epithelium

Islets of langerhans (pale staining with rich blood supply) scattered across which contain alpha, beta and delta cells which secrete glucagon, insulin and somatostatin

184
Q

Relations of the uterus

A

Anteriorly; utervesical pouch; lying either on the bladder or the small intersting [cervix lying outside the vagina = related to bladder, cervix within = related to anterior fornix]

Posteriorly: rectouterine pouch (of Douglas)

Laterally: lies to broad ligament; the ureter lies laterally to the supravaginal cervix

185
Q

Blood supply of the vagina

A

Vaginal

Uterine

Middle rectal

Inferior pudendal - supplying the lower third

Venous drainage - plexus of veins around the connective tissue in the vagina - drains to the internal iliac vein

186
Q

Relations of the abdominal aorta

Anterior

Posterior

Right

Left

A

Anterior: lesser omentum, stomach, coeliac plexus, pancreas, splenic vein, left renal vein, third part of duodenum, root of mesentery, coils of small intestine, aortic plexus, peritoneum

Posterior: bodies of upper lumbar vertebrae, left lumbar veins, cisterna chyli

Right: IVC, thoracic duct, azygos vein, right sympathetic trunk

Left: left sympathetic trunk

187
Q

Venous return of the stomach

A

Follows arteries - drains into the portal vein

Well supplied stomach - means - 3 of the 4 arteries can be ligated and not have any issue

188
Q

Why is appendicitis less common in the extremes of age?

A

Infancy = very wide lumen

Adults = obliterated

Obstruction can precipitate acute appendicitis; so less common in these age groups

189
Q

Clinical points of ureters

How it is detected during surgery?

How is it projected on radiological investigation for a stone?

A

Readily comes off with the peritoneum, may see worm-like contractions when in cotact with the forceps

At 4 points:

Along the spinous transverse processes

When it crosses sacroiliac joint

When it swings out towards the pelvic wall then reaches the ischial spine

When it turns medially towards the base of the bladder

190
Q

Rapidly developing varicoele left side

A

Left renal tumour - as testicular drainage into the left renal vein is impeded by tumour

191
Q

Sigmoid Colon

Start-finish

Mesentery important features

Relations

A

Pelvic brim to the rectosigmoid junction

Mesentery present - in some places extensive - so allows it to hang down in the pelvis

Root of the sigmoid colon crosses the external iliac vessels and left ureter

Males: rests of the bladder

Females: uterus and posterior fornix of the vagina

192
Q

Clinical points of the gallbladder:

Gangrene

Haemorrhage during cholecystectomy

Gallstone ileus

No pain when gallstone in common bile duct

Formation of mucocele of the bladder

A

Gangrene very unlikely as even if cystic artery is thrombosed - it can get blood supply from the liver bed

Pringle’s manoeuvre - compress the common hepatic artery in the free edge of the lesser omentum

Gallbladder fundus close to duodenum = gallstone can ulcerate into duodenum via cholecystoduodenal fistula - causing gallstone ileus

No smooth muscle in the walls of the common bile duct (unlike gallbladder / cystic duct) - so no pain if obstructed

Lots of mucus producing cells - if obstructed duct, bile is absorbed and excess mucus produced = cauing mucocele

193
Q

Pelvic fascia types

A

Parietal - strong, covers muscles, attaches to bone at the margins of muscles

Visceral - loose and cellular over movable structures - levator ani muscles, strong over fixed structures - prostate

194
Q

Blood supply of the colon and rectum

A

Superior mesenteric artery

Ileocolic - caecum and start of ascending colon

Right colic - ascending colon

Middle colic - transverse colon

Inferior mesentery artery

Left colic - descending colon

sigmoid - sigmoid colon

superior rectal - rectum and upper half of anal canal (lower half by inferior rectal artery)

Each branch anastamoses with its neighbour running the length of the colon - marginal artery of Drummond

Middle rectal - small and only supplies muscle coats of rectum

Superior rectal divides into two when it reaches the rectum - branches run either side

The right branch divides into two branches which descend to the level of the anal valves then anastomose with the inferior rectal artery - at 3,7,11 o’clock on lithotomy position;

accompanied by branches of the superior rectal vein –> SMA portal;

ALSO middle rectal –> IMA = systemic; inferior rectal –> pudenal –> IMA = systemic

195
Q

Physiology behind atresia and stenosis

A

Rapid growth causes obliteration of the lumen of the gut; it then recanalises

If this is incomplete - then atresia / stenosis

196
Q

What is the perineal body?

What are the attachments?

Why is it important?

A

Fibromuscular structure right in the midline between 2 triangles

Attachments are:

bulbospongiosus

superficial + deep transverse perineal muscles

levator ani

anal sphincter

Importnat as if damaged during hildbirth = disrupts levator ani attachment = weakens pelvic floor

197
Q

Blood supply of the duodenum

A

Posterior and anterior superior pancreaticoduodenal artery from the gastroduodenal artery

Posterior and anterior inferior pancreaticoduodenal artery from the superior mesenteric artery

They anastomose, run along the groove between the curve and head of the pancreas - supplying both duodenum and pancreas

Also the supraduodenal artery from the gastroduodenal artery - supplying the superior aspect of the duodenum

198
Q

Lesser sac relations

A

Anterior: lesser omentum and stomach

Superiorly: superior recess whose anterior relation is the caudate lobe of the liver

Inferiorly: projects downwards to transverse mesocolon

Left: spleen, gastrosplenic, lieno-renal ligaments

Right: epiploic foramen of winslow

199
Q

Lymphatic drainage of testes

A

Accompany veins, drain in the para-aortic nodes

200
Q

What are the muscles of:

Pelvic floor?

Pelvic wall?

A

Floor: levator ani; coccygeus

Pelvic wall: piriformis (front of sacrum); obturator internus (lateral wall of true pelvis)

201
Q

Maldescent of the testes

A

Can be into an ectopic position - at the root of the penis, the perineum or the thigh

Fail to descend (get stuck along the way) - intraabdominally (within the inguinal canal) or at the external ring

202
Q

Where is the arcuate line?

Importance

A

Halfway between the umbilicus and the pubic symphysis

Inferior epigastric vessels enter the sheath here - rupture of these due to violent contraction = rectus sheath haematoma

Spigelian hernia = lateral portion of rectus sheath @ arcuate line

203
Q

Prostatic urethra

Length

Main features

A

3cm in length

2 urethral crests on the posterior wall - forming a sinus where 15-20 prostatic ducts open

Centre of the sinus is the prostatic utricle - either side are the openings of the ejaculatory ducts (formed from the seminal vesicles + terminal vas deferens)

204
Q

Pringle’s manoeuvre

A

Compression of hepatic artery in free edge of lesser omentum

Can be compressed when cystic artery torn during cholecystectomy OR if gross haematoma during liver trauma

205
Q

Relations of the vagina

Anterior

Posterior

Superior

Lateral

A

Anterior: cervix enters the vagina above, base of the bladder and urethra (embedded in the anterior vaginal wall)

Posterior: posterior fornix - covered by peritoneum - rectouterine pouch; below is the rectum; below is the anal canal - separated by the perineal body

Superior: ureter lies superior and lateral to the lateral fornix

Laterally; pelvic fascia and levator ani

206
Q

Where is the common hepatic duct and its supraduodenal part of common bile duct lie?

A

In the free edge of the lesser omentum

Left - hepatic artery; Right - common bile duct

Posterior - portal vein

(epiploic foramen of winslow)

Posterior - IVC

207
Q

What are the peritoneal coverings of the liver?

A

Falciform ligament - between right and left lobes, attached to the anterior adominal wall, liver posteriorly - also has the ligamentum teres running in its free edge entering at the hepatic notch

divides to form the left and right peritoneal coverings as well

Left part of falciform ligament = forms part of the left triangular ligament - if traced back posteriorly and right - attaches to the lesser omentum in the fissure of ligamentum venosum

Right part of falciform ligament = forms the upper leaf of coronary ligament

Right triangular ligament formed from the upper and lower leaf of coronary ligament (around the bare area of liver)

208
Q

Blood supply of the suprarenal glands

A

Sup. suprarenal artery: branch of inferior phrenic artery

Middle suprarenal artery: branch of aorta

Inf. suprarenal artery: branch of renal artery

Venous drainage

R - short, directly into IVC

L - long, into left renal vein

209
Q

Thoracic oesophagus

Route

Relations- anterior/posterior/left/right

A

Downwards - through superior and posterior mediastinum

Slightly right at T5 then forwards and left at pass through T10 - oesophageal hiatus

Two vagus nerves form a plexus on the surface - left anteriorly, right posteriorly

Relations:

Anterior: pericardium, left common carotid, trachea, left main bronchus (which constricts it partially)

Posterior: thoracic vertebrae, thoracic duct, hemiazygous vein, descending aorta

Left: left subclavian artery, thoracic duct, aortic arch, left vagus nerve and its RLN, left pleura

Right: right pleura, azygos vein

210
Q

Development of the gut - location by blood supply

A

Foregut - into D2 of duodenum supplied by coeliac trunk

Midgut - into the 2/3 of transverse colon, supplied by superior mesenteric artery

Hindgut - into the ectodermal part of the anal canal; supplied by the inferior mesenteric artery

211
Q

Anatomy of the ureters

A

Approx 25-30cm in length; 3mm in diameter

Start at the renal pelvis where there are 2-4 major calyces, which further branch into up to 12 minor calyces - in each there is a projection of medulla = papilla [outer layer is cortex; inner is medulla]

In the papilla are the collecting ducts

Around the hilum of the kidney is the renal sinus

212
Q

Why does scrotal pain refer to abdomen?

A

Testes develop at L2/3 with its own blood, nerve and lymphatic drainage - migrates down but retains supply

Reciprocal pain from kidneys (eg kidneys stones loin to groin)

213
Q

What is the blood supply of the appendix and why is it important?

A

Appendicular artery which is a branch of the ileocolic artery

It is an end-artery - if it gets thrombosed there is rapid developmment of gangrene in the appendix

214
Q

Appendix

Length

Location

Position (x3)

Blood supply

A

5-10cm

Posteromedial aspect of the caecum; approx 2.5cm below the ileocaecal valve

Can be retrocolic/retrocaecal; pelvic; preiliac/retroileal

Blood supply - appendicular artery - a branch of the ileocolic artery; lies in the free edge of its mesentery - descends behind the ileum as a triangular fold

215
Q

Suprarenal glands

Location

Relations

A

Assymetrical

R = pyramidal, embraces upper pole of kidney

L = crescentic, medial border of kidney above hilum

Anterior:

R - IVC, liver; L - stomach, across lesser sac

Posterior: diaphragm

Inferior: kidney (upper poles)

216
Q

Importance of hepatic lymph nodes for gastric cancer

A

Retrograde spread to the hepatic nodes around porta hepatic - compress the bile ducts causing obstructive jaundice

Complex network aorund the stomach means - if coeliac nodes get involved - treatment is very difficult

217
Q

Nerve supply of the bladder

A

Efferent parasympathetic of S2,3,4 accompany vesical vessels to supply motor fibres to bladder wall + inhibotory fibres to internal sphincter

Efferent sympathetic carry inhibitory fibres to muscle walla nd motor fibres to internal sphincters

External sphincter = striated muscle, by pudendal nerve

Sensory fibres for the distension of the bladder - by both sympathetic and parasympathetic

218
Q

Stalked body on testes / epididymis

A

Appendix testes / appendix epididymis (hydatid of morgagni)

found on upper extremity

219
Q

What is the porta hepatis?

A

Gateway to and from the liver

Contain the common bile duct anteriorly, hepatic artery proper in the middle, portal vein posteriorly

Lymph nodes = enlarge during metastasis cause obstructive jaundice

220
Q

What is the femoral sheath?

A

Propagation of fascia along the femoral artery, vein and canal

anteriorly - transversalis fascia

posteriorly - iliacus fascia

221
Q

Structures responsible for forming the urogenital tract

A

Pronephros (3rd week) - transient and never functions

Mesonephros (4th week) - degenerates but has a duct (mesonephric duct) which persists - forms the vas deferens and epididymis

Metanephros (5th week) - connected via the metanephric duct (diverticulum of the mesonephric duct) - invaginates the metanephros and branches - forming ureters, calyces, pelvis, collecting ducts - this fuses with the proximal part of tubular system + glomeruli formed in the metanephros (others are formed from the duct)

Mesonephric duct loses connection with the renal traact - KIDNEY THEN DEVELOPED

222
Q

Formation of Meckel’s Diverticulum

A

Persistence of the communication of the primitive midgut to the yolk sac

It can attach to the back of the umbilicus by a fibrous cord - remnant of the vitellointestinal duct

Important as it can act as a fixed point for small bowel volvulus

Can also open onto the skin via the duct

223
Q

Blood supply of the kidney

Order of structures from hilum of kidney

A

Renal arteries at L1

Renal vein passes aorta immediately below SMA origin; drains into IVC

Left vein longer than right = received tributaries of gonadal and adrenal vein

Anterior to posterior: vein, artery, ureter

224
Q

Lymphatic drainage of the rectum

A

Along bowel wall - along blood vessels - to the root of SMA/IMA - then to cisterna chyli

Upper 2/3 rectum = superior rectal nodes –> inferior mesenteric nodes

Lower 2/3 rectum = superior rectal nodes–> inferior mesenteric nodes + internal iliac nodes

Anal canal above dentate line = superior rectal nodes –> inferior mesenteric nodes + internal iliac nodes

Anal canal below dentate line = inguinal nodes primarily

Useful in carcinoma - clearning the blood vessels + resection of the mesentery = remove affected lymph nodes

225
Q

Coccygeus

Origin

insertion

Nerve

Action

A

Spine of ischium

Side of coccyx and lowest part of sacrum; same attachments as sacrospinous ligament

Perineal branch of S4

Holds the coccyx in its natural forward position

226
Q

Cellular structure of fallopian tube

A

Cilliated columnar epithelium - lies in longitudinal ridges

Muscular layers with outer longitudinal and inner circular muscles

Ova is propelled by muscular action, cilia and lubricating fluid

227
Q

Second part of the duodenum

Direction

Main features

Relations

A

As a curve around the head of the pancreas

Bile ducts and pancreatic ducts open at the duodenal papilla on its posteromedial side (marks the division of the foregut and hindgut)

Above it is the accessory duct of Santorini

Relations: Anteriorly - transverse colon, posteriorly - right kidney and ureter

228
Q

Rotation of the midgut

A

Pushed into the vitelloinstetinal duct where it rotates around to the left along the axis of the superior mesenteric artery - this causes D2.3.4 to be fixed retroperitoneally

229
Q

Narrowest parts of the ureters

A

At the pelviureteric junction

At the pelvic brim

Vesicourethral junction

230
Q

Relations of the rectum

A

Anteriorly:

Males: rectovesical pouch, base of bladder, seminal vesicles and prostate (separated here by the rectoprostatic fascia known as fascia of denonviliers - this is key in reducing the spread of prostatic carcinoma posteriorly);

Females: rectouterine pouch (of Douglas), posterior wall of vagina

Upper 2/3 of rectum has peritoneum anteriorly - this relates to coils of small intestine, and in the rectovesical/uterine pouch the sigmoid colon

Posterior: coccycx, sacrum, pre-sacral nerves, middle sacral artery

Laterally: below the peritoneal reflection - levator ani and coccygeus

231
Q

Parts of the uterus

A

Fundus, body, cervix

232
Q

Hypermobility of kidneys

Where does blood from a traumatic kidney rupture / pus from a perinephric abcess go?

A

Can move up/down within fascia but not side-to-side

Tracks down the fasia into the pelvis - as it is open inferiorly

233
Q

What do the branches of the sympathetic chain supply?

Why is this important?

A

Plexuses around abdominal aorta; hypogastric plexus (aka presacral nerves) - to supply pelvic viscera (does this by supplying plexuses distributed along the internal iliac artery

AAA repair can damage plexuses (aortic and hypogastric) causing ED
Lumbar sympathectomy (2,3,4 ganglia of chain) - to treat plantar hyperhidrosis or vasospastic conditions of lower limb
234
Q

Femoral ring composition

A

Medial part of femoral sheath

Anterior: inguinal ligament

Medially: lacunar ligament (abnormal obturator artery can be present - can cause issues during femoral hernia repair

Posterior; pectineal ligament

Laterally: femoral vein

235
Q

External oblique

Origin

Insertion

Direction of fibres

Importance of lower border - landmarks

A

Outer surface of lower 8 ribs

Anterior portion of iliac crest, pubic tubercle, pubic crest, linea alba

Downwards and medially

Lower border between ASIS and pubic tubercle = inguinal ligament

236
Q

What can be palpated on a DRE?

A

Both:

Anorectal ring

Coccyx

Sacrum

Ischiorectal fossa

Ischial spine

Males:

Prostate

Seminal vesicles (sometimes)

Females:

Perineal body

Cervix

Ovaraies (sometimes)

mr C.S. (4 decks)

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