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Anatomy Surgery 2 Flashcards

1
Q

Extension of the breast

A

From ribs 2-6

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2
Q

Level of the nipple

A

4th ICS

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3
Q

Retraction of the nipple is caused by:

A

Pulling on the lactiferous ducts

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4
Q

Skin dimpling in Breast Ca is caused by:

A

Shortening of Cooper’s ligament

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5
Q

Interference with lymphatic drainage of the breast

A

Peau d’ orange sign - thickened, leather like appearance of the skin

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6
Q

Innervation: muscles of facial expression

A

Cervical branch of CN VII

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7
Q

Level of hyoid bone

A

C3 or C4

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8
Q

Infrahyoid muscle that depresses the larynx

A

Sternothyroid

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9
Q

Hyoid muscles innervated by C1 nerve

A

Geniohyoid, Thyrohyoid

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10
Q

Weakness of Trapezius muscle - cannot shrug and abduct the arm

A

Accessory nerve lesion - crosses the occipital triangle

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11
Q

Triangle crossed by external jugular vein and subclavian artery

A

Subclavian/Suboccipital Triangle

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12
Q

Level of Thyroid Gland

A

C5 to T1 vertebra

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13
Q

Narrow tube that connects the thyroid gland to the tongue

A

Thyroglossal Duct - normally atrophies and disappears

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14
Q

Condition associated with esophageal atresia resulting to Polyhydramnios

A

Tracheoesophageal Fistula

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15
Q

Abducts the vocal cords

A

Posterior cricoarytenoid

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16
Q

Adducts the vocal cords

A

Lateral cricoarytenoid

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17
Q

Relaxes the vocal cords

A

Thyroarytenoid

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18
Q

Tenses the vocal cords

A

Cricothyroid - external branch of SLN

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19
Q

RLN more commonly injured

A

Left - hooks around arch of the aorta

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20
Q

Nerve supply to the diaphragm

A

Phrenic - motor (from C3, C4 and C5)

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21
Q

Blood supply of nose

A

Hasselbach’s plexus (anterior), Woodruff’s plexus (posterior)

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22
Q

Odontogenic tumor that may erode the bone cortex. Radioluscent soap bubble appearance on xray

A

Ameloblastoma - Tx is resection

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23
Q

Innervates the muscles of mastication

A

3rd division CN V

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24
Q

Sentinel node of laryngeal SCC

A

Delffian node - prelaryngeal node

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25
Q

Facial nerve exits what foramen

A

Stylomastoid foramen

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26
Q

Most common salivary gland malignant tumor

A

Mucoepidermoid Ca

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27
Q

Nerves protected during Mandibulectomy

A

Hypoglossal nerve inferiorly, Lingual nerve superiorly

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28
Q

Location of thyroid isthmus

A

C2-C4

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29
Q

Anatomic landmark where RLNs are prone to injury

A

Ligament of Berry

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30
Q

RAI imaging for lingual thyroid or to search for residual thyroid after thyroidectomy

A

Iodine 123

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31
Q

RAI used to screen and treat differentiated thyroid Ca

A

Iodine 131

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32
Q

Screening method for undifferentiated or anaplastic thyroid Ca

A

PET scan

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33
Q

Most common thyroid Ca and has the greatest tendency to invade LN

A

Papillary Ca

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34
Q

Medullary thyroid Ca: worst prognosis

A

Familial type - MEN 2B

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35
Q

FNAB of Anaplastic Thyroid Ca

A

Giant multinucleated cells

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36
Q

Tx for Thyroid Lymphoma

A

CHOP regimen - Cyclophosphamide, Doxorubicin, Oncovin/Vincristine, and Prednisone

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37
Q

Most common malignancy that metastasize to the thyroid

A

Renal Cell Ca

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38
Q

Sharp indentation that approximates the junction of the body and pyloric part of the stomach

A

Angular incisure/notch

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39
Q

Portal vein is made of:

A

Superior mesenteric vein + splenic vein

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40
Q

Rule out what Ca in gastric ulcer

A

Gastric adenocarcinoma

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41
Q

Most common type of Gastric Ulcer

A

Type I - found in antral lesser curvature, blood type A

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42
Q

Caused by destruction of the pyloric sphincter resulting to abrupt delivery of hyperosmolar load to the small intestines

A

Dumping Syndrome

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43
Q

Most common pancreatic tumor in patients with MEN I

A

Gastrinoma

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44
Q

Diagnosis of ZES

A

Serum gastrin more than 200pg/mL after a secretin challenge

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45
Q

Gastrinoma Triangle or Passaro’s Triangle

A

Pancreatic neck, Porta hepatis, 3rd portion of duodenum

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46
Q

Clinical Triad of ZES

A

Hypersecretion of HCl, severe PUD, Gastrinoma

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47
Q

Large, tortuous submucosal artery in the proximal stomach. Pulsations cause ulceration of the overlying mucosa causing intraluminal bleeding

A

Dieulafoy’s Lesion

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48
Q

Most common form of Gastric Ca

A

Gastric Adenocarcinoma - dysplasia as universal precursor

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49
Q

Tx for gastric adenocarcinoma <2 cm

A

Endoscopic Mucosal Resection - tumors limited to mucosa or submucosa

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50
Q

Diffuse neoplasm involving the entire stomach giving it a “leather bottle” appearance

A

Linitis plastica

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51
Q

Periumbilical node in Gastric Adenocarcinoma

A

Sister Mary Joseph’s Node

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52
Q

Peritoneal nodes in Gastric AdenoCa, palpable on rectal examination

A

Blumer’s Shelf

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53
Q

Tx goal of Gastric AdenoCa

A

Resection of all tumor with 5cms grossly negative margins

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54
Q

Standard operation in Gasttic AdenoCa

A

Radical Subtotal Gastrectomy - remove distal 75%

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55
Q

Gastric Lymphoma arises from MALT. Majority are what type?

A

Non Hodgkin’s B Cell Type

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56
Q

Presents like gastric adenocarcinoma with B symptoms (fever, weight loss, night sweats)

A

High grade MALT lymphoma

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57
Q

Tx for low grade MALT lymphoma

A

H. Pylori eradication

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58
Q

GIST arise from the?

A

Interstitial cells of Cajal - pacemaker in GI tract

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59
Q

Tumor markers of GIST

A

c-KIT (CD 117) and CD 34

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60
Q

Most common type of GIST

A

Epithelial cell stroma

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61
Q

Tx for GIST

A

Wedge resection, Imatinib (Gleevec) for unresectable or metastatic GIST

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62
Q

Gastric carcinoids arise from?

A

Gastric ECL cells

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63
Q

Most common type of Gastric Carcinoid

A

Type I - women with hypergastrinemia, small but multiple, low malignant potential

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64
Q

Type of Gastric Carcinoid that occurs in MEN I and ZES

A

Type II - higher malignant potential

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65
Q

Type of Gastric Carcinoid that presents with Carcinoid Syndrome

A

Type III - solitary, among men

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66
Q

Biopsy: diffuse hyperplasia of surface mucus secreting cells and decrease parietal cells

A

Hypertrophic Gastropathy (Menetrier’s Disease) - protein losing enteropathy and hypochlorhydia

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67
Q

Presentation is dilated mucosal blood vessels in the distal stomach

A

Watermelon Stomach (Gastric Antral Vascular Ectasia)

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68
Q

Most common position of the appendix

A

Retrocecal

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69
Q

Nerve that can be possibly injured during appendectomy

A

Iliohypogastric nerve - weakening of anterior abdominal wall

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70
Q

Used as a landmark during OR to identify the location of the appendix

A

Anterior taenia

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71
Q

Where is McBurney’s Point?

A

Lateral 1/3 from ASIS to umbilicus

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72
Q

Appendicitis: pain on extension of right thigh

A

Psoas sign - tip of appendix is retrocecal

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73
Q

Appendicitis: pain on passive internal rotation of the flexed right thigh with the patient in the supine position

A

Obturator Sign - tip of the appendix is on the pelvis

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74
Q

CT scan findings in Appendicitis

A

Enlarged enhancing appendix (>6mm), periappendiceal fat stranding, wall thickening

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75
Q

Complication of appendicitis. A mass of inflamed, matted intestine and omentum with little or no discrete collection of pus

A

Phlegmon - complication of gangrenous acute AP

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76
Q

Most important pathogen in AP related infection

A

Bacteroides fragilis

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77
Q

When is an incidental appendectomy routinely performed?

A

Ladd’s procedure - correction of intestinal malrotation with volvolus in children

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78
Q

Most common malignancy of the appendix

A

Carcinoid - usually at the tip

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79
Q

Tx for adenocarcinoma of the appendix

A

Right hemicolectomy

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80
Q

Diffuse collection of gelatinous fluid and mucinous implants on peritoneal surfaces and omentum

A

Pseudomyxoma peritonei - Tx with surgical debulking (appendectomy, omentectomy, TAHBSO)

81
Q

Fatty tags in the large intestine

A

Appendices epiploicae

82
Q

Longest, largest and most mobile part of the large intestines

A

Transverse colon

83
Q

Blood supply of cecum

A

Anterior/posterior cecal artery from ileocolic artery (SMA)

84
Q

Blood supply of appendix

A

Appedicular artery from ileocolic artery (SMA)

85
Q

Venous drainage of appendix

A

Appendicular vein to posterior cecal vein (SMV)

86
Q

Blood supply of ascending colon

A

Ileocolic and right colic artery from SMA

87
Q

Blood supply of transverse colon

A

Middle colic artery from SMA and L colic artery from IMA

88
Q

Blood supply of descending colon

A

L colic and sigmoid artery from IMA

89
Q

Blood supply of sigmoid colon

A

Sigmoid artery from IMA

90
Q

5 inches long, begins in front of 3rd sacral vertebrae and ends in front of the tip of the coccyx

91
Q

Blood supply of the rectum

A

Superior rectal from IMA, middle rectal from internal iliac and inferior rectal from internal pudendal

92
Q

Muscles in internal and external anal sphincter

A

Internal - circular muscles, external - 3 striated voluntary muscles

93
Q

Dentate/Pectinate/Anorectal Line

A

Junction between the superior (endoderm) and inferior (ectoderm) parts

94
Q

Muscle that forms a U shaped sling resulting to a 90 degree perineal flexure

A

Puborectalis Muscle

95
Q

Disease due to absence of ganglionic cells in the myenteric and submucosal plexuses. Mutations of RET proto-oncogene

A

Hirschsprung Disease (Colonic Aganglionosis) - sigmoid colon and rectum, failure of internal anal sphincter to relax

96
Q

Blood supply to the upper part of the anal canal

A

Superior rectal artery from IMA

97
Q

Lymphatic drainage of upper part of anal canal

A

Inferior mesenteric LN

98
Q

Blood supply of lower anal canal

A

Inferior rectal artery from internal pudendal artery

99
Q

Lymphatic drainage of lower part of anal canal

A

Superficial inguinal nodes

100
Q

Sensations: Upper vs Lower Anal canal

A

Upper - stretch, Lower - pain temperature touch pressure

101
Q

Outpouching of a remnant of the proximal portion of the yolk sac

A

Meckel’s Diverticulum

102
Q

Diverticulum located 2ft from ileocecal junction, 2in long, and may contain ectopic gastric or pancreatic cells

A

True Diverticulum - bleeding with ulceration of ectopic cells

103
Q

True or false: R and L colon are retroperitoneal while transverse and sigmoid colon are intraperitoneal

104
Q

Widest portion of the colon with the thinnest wall

A

Cecum - high risk of perforation

105
Q

Most common area of obstruction in the colon and high risk for volvulus

A

Sigmoid - narrowest portion

106
Q

Twisting of an air filled segment of bowel about its narrow mesentery

A

Colonic volvulus - counterclockwise usually, apex is opposite where it twists

107
Q

Abdominal x-ray of sigmoid volvulus

A

Inverted U shape, sausage like loop

108
Q

Indicates successful reduction in sigmoid volvulus

A

Passage of air and feces through soft rectal tube

109
Q

Emergent procedure for a septic patient with volvulus (bowel unprepared)

A

Hartmann’s Procedure - resection of sigmoid colon with construction of an end colostomy

110
Q

Proctoscope findings in sigmoid volvulus

A

Swirl sign or the area where it twists, procedure contraindicated for necrotic tissue

111
Q

Type of colostomy where midline laparotomy needed for take down

A

Devine’s colostomy

112
Q

Plain abdominal x-ray of Cecal Volvulus

A

Kidney shaped, air filled structure in the LUQ - does not resolve with NGT placement

113
Q

Tx for cecal volvulus

A

R hemicolectomy with primary ileotransverse anastomosis

114
Q

Transverse colon loops that are interposed between the liver and diaphragm

A

Chilaiditi’s syndrome - at risk for volvulus

115
Q

Tx of rare, R sided diverticulitis

A

Segmental ileocecal resection

116
Q

Most common cause of life threatening colonic hemorrhage

A

Diverticular disease

117
Q

IBD that cannot be cured with surgery

A

Crohn’s Disease

118
Q

Most common location of Crohn’s disease

A

Terminal ileum, but can happen anywhere

119
Q

Pathologic findings of Crohn’s Disease

A

Transmural involvement, skip lesions, non caseating granulomas, perianal fistulas, cobblestoning strictures

120
Q

Most common type of colonic polyp

A

Hyperplastic, not pre-malignant

121
Q

Colonic polyp that can be malignant if it occurs with a syndrome

A

Hamartomatous or Juvenile - occurs at any age

122
Q

Colonic polyp where malignancy is related to its size (>2cm)

A

Adenomatous

123
Q

FAP with extraintestinal manifestations (mandibular osteomas, hypertrophy of pigmented retinal epithelium, desmoid tumors)

A

Gardner’s Syndrome

124
Q

FAP with brain tumors (glioblastoma)

A

Turcot’s Syndrome

125
Q

Polyposis + epidermal changes (alopecia, cutaneous pigmentation, atrophy of nails)

A

Cronkite Canada Syndrome (AD)

126
Q

Hamartomatous polyps of all 3 embryonal cell layers

A

Cowden’s Syndrome - with breast Ca, leiomyomas, thyroid disease and facial trichilemmomas

127
Q

Polyposis on jejunum, ileum and rectum. With melanin spots on lips and buccal mucosa

A

Peutz-Jegher’s Syndrome

128
Q

Mutation in FAP resulting to 100% lifetime Ca risk

A

SPC mutation, chromosome 5q

129
Q

Mutations in Hereditary Nonpolyposis Colon Cancer

A

hMLH1 and hMSH2 mutation - 85% risk Ca, screening colonoscopy at 20 to 25yrs

130
Q

Distinct curvatures that project into the lumen of the rectum

A

Valves of Houston

131
Q

Retrosacral fascia of rectum

A

Waldeyer’s fascia

132
Q

Anterior fascia of rectum

A

Denonvillier’s fascia

133
Q

Levator ani muscles that make up the pelvic floor

A

Pubococcygeus, Ileococcygeus, Puborectalis muscle

134
Q

Surgical anal canal

A

From anorectal ring to anal verge

135
Q

At most risk during lateral mobilization of the rectum

A

Pudendal nerve - supplies pain, temperature and touch sensation to lower anal canal

136
Q

At most risk during posterior mobilization of the rectum

A

Hypogastric plexuses - retrograde flow of sperm to the bladder

137
Q

Etiology of rectal prolapse

A

Internal intussusception, outlet obstruction, long term laxative use

138
Q

Thiersch procedure for rectal prolapse

A

Use a wire to tighten the sphincter

139
Q

Common locations of hemorrhoids

A

3, 7 and 11 o’clock position

140
Q

Tear in anoderm just distal to the dentate line

A

Anal fissure - pain causes spasm of the internal sphincter

141
Q

Surgical Tx for anal fissure

A

Lateral internal sphincterotomy to relieve spasm

142
Q

Complication of posterior sphincterotomy as a repair of anal fissure

A

Keyhole deformity - frequent soiling of underwear

143
Q

Chronic form of anorectal abscess

A

Fistula-in-ano

144
Q

Fistula-in-ano: Goodsall’s Rule

A

Anterior straight, posterior curved

145
Q

Well differentiated keratinizing anal neoplasm often caused by HPV infection

A

Squamous cell Ca - Tx with wide local excision with 2cm margin, if sphincter affected do APR

146
Q

Intraepidermal squamous cell Ca of anus treated with wide excision

A

Bowen’s Disease

147
Q

From apocrine glands, patients present with severe pruritus. Treat with wide excision of APR for advanced disease

A

Paget’s Disease

148
Q

Treatment for Epidermoid Ca of anus

A

Nigro protocol - 5 FU, Nitromycin, External Beam Radiation

149
Q

Pain, fever and ileus appearing 2-3 weeks after an attack of pancreatitis

A

Pseudocyst - fibrous wall surrounding a collection of pancreatic juice and necrotic or suppurative pancreatic tissue

150
Q

Best Tx for pseudocyst of pancreas

A

Internal drainage

151
Q

Most common pancreatic malignancy

A

Adenocarcinoma - usually at the head

152
Q

Definitive and potentially curative Tx of periampullary Ca of pancreas

A

Whipple’s surgery - pancreaticoduodenectomy

153
Q

How do you know if the pancreatic head is resectable?

A

If you can palpate the SMA posteriorly

154
Q

Dreaded complication of Whipple’s surgery

A

Leak from pancreaticojejunostomy - peritoneal cavity digested by pancreatic enzymes

155
Q

Most common functional endocrine tumor of the pancreas

A

Insulinoma - _insulin and C peptide, _ glucose

156
Q

Whipple’s Triad of Insulinoma

A

Symptomatic fasting hypoglycemia, serum glucose <50mg/dL, relief of symptoms with glucose administration

157
Q

Tx for Insulinoma

A

Enucleation, if >2cm and close to main pancreatic duct Whipple’s Procedure

158
Q

Pancreatic tumor located at the tail. Causes watery diarrhea, hypokalemia, and achlorhydia

A

VIPoma - usually malignant

159
Q

Pancreatic tumor with presence of necrolytic migratory erythema

A

Glucagonoma - found at body and tail, metastatic

160
Q

Gastrinoma Triangle

A

Cystic duct, junction of the 2nd and 3rd portions of the duodenum, junction of the neck and body of the pancreas

161
Q

First, shortest, widest and fixed (retroperitoneal) part of the small intestine

A

Duodenum - C shaped, 25cm long

162
Q

Duodenum: attachment site for hepatoduodenal ligament of lesser omentum

A

Superior (1st) - anterolateral to L1

163
Q

Duodenum: descends along the R sides of L1 to L3

A

Descending (2nd)

164
Q

Blood supply upper part of duodenum

A

Superior pancreaticoduodenal artery (gastroduodenal - hepatic - celiac)

165
Q

Blood supply of lower duodenum

A

Inferior pancreaticoduodenal (SMA)

166
Q

Venous drainage of duodenum

A

Superior/Inferior pancreaticoduodenal veins to portal vein

167
Q

Most common location of duodenal ulcers

A

Anterior wall on first part - most common site of perforation

168
Q

Duodenal wall ulcers that may lead to severe hemorrhage and perforate into the pancreas

A

Posterior wall ulcer - erode gastroduodenal artery

169
Q

Anatomic landmark of GIT that also supports the duodenojejunal flexure

A

Ligament of Treitz - demarcates duodenojejunal junction

170
Q

True or false: jejunum lies in RLQ while ileum lies in LUQ

A

False - Jejunum lies in LUQ, Ileum lies in RLQ

171
Q

Blood supply of jejunum and ileum

A

SMA - arterial arcades - vasa recta

172
Q

Jejunum vs Ileum

A

Jejunum - red color, wall thick and heavy, greater vascularity, long vasa recta, few and large arcades, less fat, large and tall plicae circularis, few lymphoid nodules

173
Q

Jejunum vs Ileum

A

Ileum - pink color, thin and light wall, less vascularity, short vasa recta, many arcades, more fat, sparse plicae circularis, many lymphoid nodules (Peyer’s Patches)

174
Q

Most common location of intussusception

A

Ileocecal - R sided colicky pain, currant jelly stools

175
Q

Mucosal folds in the small intestine

A

Plicae circulares, Valvulae conniventes, Valves of Kerkring

176
Q

Strongest layer of small intestine

177
Q

Development of small intestines

A

Duodenum - foregut, Jejunum and Ileum - midgut

178
Q

Lymph node aggregates in the ileum

A

Peyer’s Patches

179
Q

Produce an alkaline secretion to protect the GI against acidic gastric chyme

A

Duodenal Brunner’s Glands

180
Q

Cells in the SI that aids in digestion and absorption of dietary nutrients

A

Enterocytes

181
Q

Found at the base of the crypts of Lieberkuhn. Role on phagocytosis and mucosal defense

A

Paneth Cells

182
Q

Found above Peyer’s Patches in ileum. For antigen presentation.

A

Microfold (M) Cells

183
Q

Development of SI

A

5th week AOG - extracoelemic herniation. 10th week AOG - return to abdominal cavity, rotation around the SMA

184
Q

Absorption of Na, Cl, K, Ca, Mg, Iron and H2O

185
Q

Most common surgical disorder of the SI

A

Small bowel obstruction - 75% due to adhesions

186
Q

Most common cause of SBO among pediatric patients

187
Q

Abdominal Xray SBO:

A

Dilated small bowel loops (>3cm), air fluid levels, paucity of air in the colon

188
Q

“Intestinal housekeeper”. Determines the pattern of contraction during the fasting state

A

Migrating Myoelectric Complex (MMC) - peristaltic contraction every 90 to 120 min

189
Q

Cause of intestinal fistulas

A

80% iatrogenic - between 5th to 10th day post op, Dx through CT with oral contrast

190
Q

Most common small bowel neoplasm

A

Adenocarcinoma in the duodenum - 80% metastasis at the time of diagnosis

191
Q

Most common type of lymphoma in small bowel

A

B cell lymphoma in the ileum

192
Q

Tx for jejunal and ileal tumors

A

Segmental resection with at least 5cm tumor free margins

193
Q

Most prevalent congenital anomaly of the GIT

A

Meckel’s Diverticulum - true diverticula

194
Q

Etiology of Meckel’s Diverticulum

A

Persistence of the omphalomesenteric duct or vitelline duct

195
Q

Modality of choice to diagnose Meckel’s Diverticulum

A

Tc pertechnetate scan

196
Q

Segmental resection for Meckel’s Diverticulum

A

Bleeding, wide base, inflamed and perforated base

197
Q

Most common etiology of mesenteric ischemia

A

Arterial embolus - from L atrial thrombi, lodges to SMA

198
Q

Etiology of chronic mesenteric ischemia

A

Atherosclerotic lesions in the main splanchnic arteries (celiac, SMA, IMA)

199
Q

Gold standard diagnostic modality of choice for mesenteric ischemia

A

CT scan angiography

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